

B9 



THE SANITARY 

CARE AND TREATMENT OF CHILDREN 
AND THEIR DISEASES. 

2&eing a M>mz# of f itoe <g£gap£ 

BT 

DRS. ELIZABETH GARRETT-ANDERSON, SAMUEL C. BUSEY, 
A. JACOBI, J. FORSYTH MEIGS, and J. LEWIS SMITH. 



Prepared by request of the Trustees of the Thomas Wilson 
Sanitarium of Baltimore, Md. 



1° 







MAY 



>*?'» 






BOSTON: 
HOUGHTON, MIFFLIN AND COMPANY. 

SDtje ftitoer£i&e $m$, Cambridge, 

1881. 



&". 



X 



«*■ 



Copyright, 1881. 
By HOUGHTON, MIFFLIN & CO. 



The Riverside Press, Cambridge. 
Printed by H. 0. Houghton and Company 



PEEFACE. 



The accompanying letter, addressed to the authors of the 
essays, will sufficiently explain the motives which led to the 
publication of this volume. 

The trustees acknowledge with gratitude their apprecia- 
tion of the valuable suggestions embodied in these essays, and 
the interest which the writers manifest in the successful estab- 
lishment of the sanitarium. They trust that the spirit of 
philanthropy and science thus shown may stimulate other 
public-spirited men and women to aid in enlarging the work 
of the sanitarium, and to become the founders of like charities 
for the little sufferers in other cities. 

The public may also be interested in knowing that the 
trustees have purchased a farm of 150 acres, for the sani- 
tarium, on the Western Maryland Railroad, nine miles north- 
west of Baltimore, in a neighborhood long known for its sa- 
lubrious air, highly cultivated land, and intelligent popula- 
tion. Adjacent to it on the north is the fine estate of the 
McDonough School, of 850 acres. Gwynns Falls, a stream 
with a daily flow of 2,000,000 gallons of water, passes through 
the entire length of the farm, and a never-failing supply of 
pure water, from two large springs upon the place, can be 
forced to all parts of the property by the use of the power of 
the main stream. 

At that part of the grounds which lies along the railroad, 
where the station will be located, and through which the 



iv PREFACE. 

stream flows, are thirty acres of meadow and ten acres of 
wood land, admirably adapted for day excursions. The 
land then rises rather rapidly to a plateau of about forty 
acres, on the north, northwest, and northeast of which is a 
natural forest. This table land has a gentle slope towards 
the south, the views from it are very extensive, and it affords 
fine sites for the permanent buildings; the elevation above 
tide water is 573 feet. 

All trains will stop at the station, which is distant from 
Baltimore, in time, twenty to thirty minutes. The four city 
stations of the railroad will greatly facilitate the transporta- 
tion of the children to and from their homes. 

While the trustees believe that they have secured a site for 
the sanitarium which will, to a great extent, meet the needs 
of sick infants and their mothers during the heat of summer, 
they are not unmindful of the fact that they also have the 
opportunity of contributing largely to the advancement of 
medical science, and to the instruction of mothers in the care 
of their children. 

The building plan proposed by Dr. J. Lewis Smith, in his 
essay, and that of Mr. J. B. Robinson, architect, New York, 
prepared by request, are worthy of careful and intelligent 
study. It is probable, however, that the trustees will begin 
their work in very simple and inexpensive houses, and decide 
upon permanent buildings after they have had the experience 
of several years in the management of their trust. 

Baltimore, Md., April, 1881. 



JHILDREN . 








John Beverley Robinson , Arch t 
New York . 188! 



SKETCH OF DESIGN FOR THE 

THOMAS WILSON SANITARIUM FOR CHILDREN 




F-RONT ELEVATION . 



Beverley Robin 




PLAN OF - FIRST STORY. 




F>L_AN Of SECOND STORN'. 



Office of the Thomas Wilson Sanitarium for Children of 

Baltimore City. 

Baltimore, December 8, 1879. 
At the instance and under the supervision of the late 
Thomas Wilson, of this city, " The Thomas Wilson San- 
itarium for Children op Baltimore City," was incor- 
porated, July the second, 1875, — 

" For the purpose of securing a summer retreat for sick children 
from the heat and unheal thfulness of the city, and for such other 
kindred purposes as may he hereafter determined upon by the cor- 
pora tion." 

His Will, executed the seventh day of February, 1879, pro- 
vides as follows : — 

" I have observed for many years, with much concern, the great 
and alarming mortality which occurs each summer among young 
children deprived, by misfortune of their parents, of all opportunity 
for removal from the heated and fatal atmosphere of the city. 

" God, in his providence, did not spare to me my children, to be 
the solace of my declining years, but my pity for the sufferings of 
little children, and of their parents, is none the less, and I do not 
think that I can make a better use of some of the means of which 
God has made me steward, than in the alleviation of the pains, and 
in the prolongation of the lives, of those of whom our Saviour said, 
' Suffer little children to come unto me, for of such is the kingdom 
of heaven.' I therefore give, devise, and bequeath unto ' The Thomas 
Wilson Sanitarium for Children of Baltimore City,' a corporation 
created under the provisions of the Maryland Code of Public Gen- 
eral Laws, in relation to corporations, under my own supervision* 
.... in all a bequest of five hundred thousand dollars." 

The trustees to whom the execution of the above-men- 
tioned trust has been committed, desire to furnish themselves 
with the results of the experience and views of those whose 



VI CIRCULAR. 

attention and studies have been devoted to the sanitary care 
and treatment of children and their diseases. The trustees 
therefore at their first meeting, preliminary to the formation 
of any definite plan of procedure, determined, — 

" To correspond with a few persons at home and abroad, who are 
eminent for their experience and success in the treatment and care of 
sick children, and to obtain essays from them, to be published for 
the benefit of this and similar institutions." 

In asking such a contribution from you, the trustees have 
in mind the consideration of the best method of establishing a 
sanitarium (not a hospital, but a summer retreat)- for sick 
children, under the most favorable hygienic and local condi- 
tions that the neighborhood of Baltimore may afford. 

The land lying north and west of the city is high and pic- 
turesque, and elevations of four hundred feet above tide are 
reached by steam railways in thirty minutes, and those of six 
hundred to eight hundred feet in one hour. These districts 
have always been healthy ; the water is pure, and food of all 
kinds is plenty and cheap. The ocean is not within available 
distance, and the shores of the Chesapeake Bay are malarial. 

The trustees also desire your opinion regarding the regula- 
tions suitable for receiving and administering medically and 
otherwise to those who shall be the proper objects of their 
care, with such suggestions as may occur to you in reference 
to the character of the buildings that may be requisite — their 
grouping or isolation — how best to provide for mothers or 
nurses accompanying their children, and generally such inci- 
dental recommendations as your experience or reflection may 
commend as valuable and useful. 

The trustees wish your suggestions in reference to the most 
practicable means of lessening the risks and dangers incident 
to children exposed to the heated and impure atmosphere of a 
large city during the summer months ; also your views as to 
the best "methods of extending a general knowledge of simple 
hygienic rules for the treatment of children at home among 
the poorer classes. In the fulfillment of their duties they 



CIRCULAR. vii 

hope at least " to show a model of experiment," which may- 
prove of value as a contribution to the best means of lessening 
the mortality and promoting the welfare of young children 
here and in other large cities. 

Whilst thus indicating the nature of the information de- 
sired by them, the trustees wish you to give your thoughts in 
the method and manner which you will deem most conducive 
to their successful presentation. Should you kindly consent 
to serve us and the cause of humanity in the manner indicated, 
the trustees desire to receive the paper prepared by you, by 
the 1st of September, 1880. 

We are, very respectfully, your friends, 

FRANCIS T. KING, 
JOHN CURLETT, 
WILLIAM A. FISHER, 
JAMES CAREY THOMAS, M. D., 
GEORGE W. CORNER, 
WILLIAM H. GRAHAM, 
WILSON PROCTOR, 
Trustees of the Thomas Wilson Sanitarium of Baltimore City. 



CONTENTS. 



Page 

How can Children in a City be kept Healthy. By Eliz- 
abeth Garrett Anderson, M. D., London, England ... l 

The Mortality of Young Children : Its Causes and Pre- 
vention. By Samuel C. Busey, M. D., Washington, D. C. . 28 

On the Improvement of the Condition of Poor and Sice 
Children : General Principles. A Letter to the Hon- 
orable the Board of Trustees of the Thomas Wilson 
Sanitarium for Children. By A. Jacobi, M. D., New 
York 165 

Observations upon the Sanitary Care and Treatment of 
Children and their Diseases. In Answer to Certain 
Questions propounded by the Trustees of the Thomas 
Wilson Sanitarium for Children, of Baltimore City. 
By J. Forsyth Meigs, M. D., Member of the College of 
Physicians of Philadelphia, one of the Physicians to 
the Pennsylvania Hospital, etc., etc 206 

Causes of the Great Mortality of Young Children in 
Cities during the Summer Season, and the Hygienic 
Measures required for Prevention. By J. Lewis Smith, 
M. D., of New York 239 



THE SANITARY CARE AND TREAT 
MENT OF CHILDREN. 



HOW CAN CHILDREN IN A CITY BE KEPT 
HEALTHY,? 

BY ELIZABETH GARRETT ANDERSON, M. D., 

London, England. 

It is plain that this question is a very much more complex 
one than any which concerns itself only with the study of the 
conditions which are ideally best for the production of health 
in children or in adults. Town life is not what suits children, 
and the problem of how far and by what methods we can get 
them to submit to unnatural conditions without being seri- 
ously injured is a much more intricate one than that which 
seeks only to determine what it is which would be absolutely 
best suited to them. 

But Arcadia is a long way off, behind, or possibly in front 
of us. We have to deal with life as it is, and this includes 
many thousands of children dwelling in a city, with all its 
dangers and difficulties. It is of no use to lament this ; we 
must accept the fact and see how far the evils of such a life can 
be corrected or avoided. The first step in the inquiry is taken 
by asking what it is that children most want in order to be 
in sound health. We know that the essentials are fresh air, 
suitable and abundant food, to have come of a healthy stock, to 
be guarded from accidental contact with sources of contagion, 
to be protected from all the influences which would interfere 
with the normal development and stability of the nervous sys- 
tem, — such as undue and too early toil, anxiety, want of ad- 
equate rest and recreation, unsuitable or excessive excitement, 



2 HOW CAN CITY CHILDEEX BE KEPT HEALTHY? 

— and in early infancy, at any rate, to be the objects of a mi- 
nute and all-watchful care. "We shall have occasion to study 
these essentials at length further on ; all that is necessary now 
is to notice them in a passing way. having the conditions of 
town-bred children in our minds as we do so. It may be well 
here to suggest the thought that these essentials, though 
rightly so-called, are not all and everywhere of equal value. 
Pure air, for instance, is of such paramount importance that 
where it can be had children live and thrive upon poor food, 
in squalor and dirt, and with the minimum of care ; whereas 
without pure air, or in air distinctly impure, very few chil- 
dren can thrive, however well they are supplied with all the 
other essentials of health ; and no doubt the superlative im- 
portance of fresh air in children's hygiene partly works by 
the influence its presence has in diminishing the importance 
of food, cleanliness, and care. "With it children can bear neg- 
lect and the complete absence of minute care in a way which 
would be impossible to those breathing an air even but mod- 
erately impure. They can do without wisdom in their moth- 
ers with a comparative immunity from harm which no town- 
bred child can imitate. If the commonly received essentials 
of health were classified according to their relative impor- 
tance, fresh and pure air would, for children at any rate, take 
the first place, and cleanliness the last. Even in towns, 
where the skin seems to be more neglected than in the coun- 
try, or where perhaps the dirt is more enamelling in character, 
and therefore more injurious, it is surprising how little harm 
seems to result from dirt, and how little mere skin cleanli- 
ness seems to benefit the health. In London we should be dis- 
posed to say that as a rule, among the lowest classes, the dirty 
are more vigorous than the clean, and to explain it by no- 
ticing that the dirtiest are those whose trades are carried on 
out-of-doors. The moral influence of dirt is probably much 
more serious and damaging than its physical effect. 

When we begin to consider in detail those conditions which 
we have called hygienic essentials, the difficulties which beset 
town-bred children become very evident. Let us take pure 



nOW CAN CITY CHILDREN BE KEPT HEALTHY? 3 

air first in the list, as it indeed well deserves to be taken. 

By the term " pure air " we mean an air containing no appre- 
ciable admixture or the exhalations of men or animals, free 
from malaria and sewer gases, from the products of combus- 
tion, especially when this is imperfect : free from the products 
of decomposition of either animal or vegetable matter, from 
the organic £erms which result from a rank vegetation ; an air. 
finally, which can move, and which is not shut off from the 
influence of the sun. Such conditions are best fulfilled in sea 
or mountain air. but by no means invariably even in these. 

For children, sea air has qualities which apparently none 
other can rival; but whether these are the result of the small 
amount of contained iodine, or of a higher degree of purity 
than that of ordinarily good mountain air. or of its more 
powerfully stimulating effect upon the functions of nutrition 
and assimilation, is still undetermined. It is at once apparent 
that to children in towns pure air. as now described, is an im- 
possible luxury. Rich and poor alike must do without it. and 
the only practical points worth prolonged consideration are. how 
can the air be made as little impure as is possible under the 
conditions, and how can the :l.i. .: '-i\ get as much as possible of 
this only moderately impure air ? In dealing with the first 
of these two points, let us think of the air first as it is in the 
town, and then as it is in the children's homes. Outside the 
houses the air will of course be greatly influenced by the po- 
sition of the town, its elevation, its exposure, the presence or 
absence of marshes or other sources of malaria, the greater 
or less closeness of the houses, the width and aspect of the 
streets ; whether these are for the most part properly laid out 
and open to a through current of air or not. the system of 
drainage adopted, the amount of fall provided in the main 
drains, the abundance of the water supply for flushing the 
sewers, the total annual rainfall and its distribution through 
the various seasons, the state of the streets as to cleanliness. 
that is, the rate of removal of refuse, of dust, etc.; the pres- 
ence or absence of noxious trades, more especially manufacto- 
ries which produce poisonous vapors and dense smoke, the 



4 HOW CAN CITY CHILDREN BE KEPT HEALTHY? 

sanitary condition of slaughter-houses, mews, stables, and 
markets, and the presence or absence of grave-yards. All 
these and similar influences must greatly affect the degree of 
impurity of town air. Assuming that a town is efficiently 
drained and cleansed, and free from malarial or miasmatic in- 
fluences, the point of chief importance of all those just enu- 
merated is the density of the population. Where the streets 
are narrow, the houses high and crowded, and the open spaces 
few, there must the air be most laden with impurities, there 
must it be the farthest removed from that aseptic condition 
which young life especially needs. 

Passing from the air of the street to that in the children's 
homes, we see that at the best it cannot be better than the 
outside air, and is almost certain to be very much worse. It 
must contain all the impurities of the outer air, and it can 
scarcely avoid having a good many of its own. In the first 
place, there are but few houses which are not liable to the in- 
vasions of sewer gas, either by direct communication with 
the drains, by the absence of adequate sewer ventilation, 
by the leakage of pipes, by drains being riddled with rat- 
holes, or having an insufficient fall, or getting their outlets 
blocked. Even in good houses, where the occupier would 
not hesitate a moment to spend any necessary sum to insure 
the absence of these defects, if suspected, they are frequently 
present for months before they are discovered, and are as 
often the source of illness, or of debility and languor. It is 
easy to understand that they must be still more often present 
when the house is sub-let to many families of tenants, and 
when the owner desires to spend as little upon it as is pos- 
sible. The second great source of the added impurity of 
house air over and above the impurity outside, is found in 
the crowding which prevails in the poorer quarters of every 
large city. Adequate ventilation is simply impossible wher- 
ever a whole family occupies one small room. Even in the 
summer time, with open windows, the air does not move with 
sufficient rapidity ; it becomes gradually saturated with exha- 
lations ; and at night and in the winter it is still w r orse. The 



HOW CAN CITY CHILDREN BE KEPT HEALTHY? 5 

immense importance of this point, especially to children, is at 
once seen when we think of the number of hours passed in 
sleep. Well-cared-for children are glad to sleep eleven or 
twelve hours out of the twenty-four till they are seven years 
old, unless they are exceptionally vigorous ; and though poor 
children do not as a rule get a chance of such long nights as 
this, they are probably in bed nine or ten hours daily. 
Nothing can make up to them for the evil of breathing fetid 
and impure air uninterruptedly for so large a part of each 
day. In the day-time the injurious influence of crowding 
appears to be most felt by the more respectable sections of 
the town poor. Especially is this true of the children. It is 
very striking in London to notice how much more robust the 
children of the careless class of mothers are when past early 
infancy than those of the careful. Roaming the streets all 
da} r , playing marbles, dancing to the hurdy-gurdies, or watch- 
ing Punch and Judy, may be bad training for the morals, but 
it suits the children's health much better than careful guard- 
ing and keeping at home. Imperfect as the air of the streets 
is, it is better than that of the houses ; and where, as in 
London, there is no malaria to fear and guard against, the 
best remedy for the indifferent quality of town air is to take 
a great deal of it in quantity. Nothing can exceed the value 
of open spaces in cities to all classes, but more particularly to 
young children, and to the poor generally. In London, 
though we are better off for parks and large open areas than 
they are in most of the cities in Europe, we yet sadly need 
the multiplication of small and handy spaces within two or 
three minutes' run of the children's homes. Probably no 
single act would confer half so much benefit upon the London 
poor as buying up the private rights to the squares in the 
poorer and more crowded quarters, and throwing them open 
to the public. But even where everything possible is done 
to improve the purity of city air, and to increase the quantity 
available for respiration, it cannot either in quality or quan- 
tity compare with pure country air, and children cannot be 
induced to ignore its inferiority. Even to the classes inhab- 



6 HOW CAX CITY CHILDREN BE KEPT HEALTHY? 

iting large and airy houses in the best quarters of a town, it 
is almost a sine qua non, if the children are to grow up strong 
and healthy, to take them into the country once a year. 
How much more necessary must such a change be to children 
living in narrow, closely-packed streets and courts, in houses 
where every room is as full as it can be packed with, human 
beings ! 

It must moreover not be forgotten, that the imperative 
necessity for occasional escape from city air which exists for 
all children is indefinitely more urgent wherever the average 
temperature of the three summer months amounts to 70 c F.. 
or above it. In this case it is no longer a question of keep- 
ing children healthy, but of keeping them from dying. In 
London, the moment the average daily temperature exceeds 
TO 3 F., children die in numbers every week from diseases 
which seem to depend intimately upon the combination of a 
moderately high temperature and city air. 

How it is, exactly, that summer diarrhoea so frequently ac- 
companies a temperature not in itself trying to most healthy 
adults, we do not yet know. Its precise causation is still, no 
doubt, a matter of dispute ; it is impossible to explain it sim- 
ply by the presence of a certain degree of summer tempera- 
ture. Leicester, for instance, is not hotter than many other 
towns in England, in Julv and August, though its diarrhoea 
mortality is often greatly in excess of theirs. Everything 
points to the conclusion that the aetiology of infantile diarrhoea 
is complex, and that high temperature is but one of its im- 
portant factors, while impurity of air is another. Probably 
the two combined induce subtle changes in milk and other 
staples of children's food. Certainly, no one can observe the 
swiftness and certainty with which, among hand-fed and ill- 
tended children, this class of disease follows a rise of tempera- 
ture, without suspecting it to be due to the direct introduc- 
tion into their bodies of actively developing germs which the 
high temperature has supplied with one of their necessary 
conditions of activity. The fact that children who still de- 
pend mainly upon cows' milk are the chief sufferers seems to 



HOW CAN CITY CHILDREN BE KEPT HEALTHY? 1 

point to the milk as the probable vehicle by which the infect- 
ive particles obtain an entry into the child's digestive tract. 
Whether this hypothesis be true or not, it is certain that in- 
fantile summer diarrhoea, though not unknown in the country, 
is indefinitely less of a danger there to well-fed and well- 
cared-for children than it is in cities, and that the principal 
weapon with which the ravages of the disease can be com- 
bated is moving children of the most susceptible age, that is 
from eight months to two and a half or three years, into the 
country during the dangerous months of each year. Among 
the classes where this is as a rule impossible, and where no ex- 
traordinary caution as to the quality and storage of the milk 
supply is likely to be shown, summer diarrhoea will probably 
continue to be an ever-present danger if not altogether the 
scourge it is at present, so that to the question, " How could 
it be prevented ? " we are obliged to answer that, so far as 
we know now, it cannot absolutely be prevented, and that 
the utmost that sanitary science can do at present is to show 
communities where the danger lies, and individuals the only 
known protective agency. A minute and laborious study of 
the influence of heat on milk and other common articles of 
nursery food would certainly be worth making. Xow that 
fresh meat can be carried across the tropics and up the Red 
Sea from Australia to England, absolutely free from putrefac- 
tive change, and at a very moderate cost, it ought not to be 
impossible to supply young children in cities with their neces- 
sary food quite unaffected by an outside temperature of 72° 
F. or upwards. The subject is one which might well engage 
the attention of men of practical science in those towns where 
the average summer heat is recognized as one of the most 
serious enemies to infant life. In this country, though we 
are almost every year reminded for a very short time of the 
dangers of heat, a temperature of 72° F. or upwards is seldom 
maintained for more than a few days at a time, and often for 
not more than two or three weeks in all throughout the year. 
Diarrhoea is therefore not the grave and ever-present danger 
in our minds that it is in those of people living in semi-trop- 
ical towns. 



8 HOW CAN CITY CHILDREN BE KEPT HEALTHY? 

On the other hand, the damp and cold of England and 
the choking oppressive fogs of London bring a train of evils 
of their own in the direction of catarrhs, bronchitis, and 
asthma, evils which, important in themselves, are aggravated 
by the length of time to which we are exposed to them. 
Happily, however, they admit of being considerably di- 
minished by careful management, and, in the comfortable 
classes at any rate, children in London can be kept well 
through a winter lasting five or six months very much more 
easily than they can be through even two months of high 
summer temperature. The immediate evils resulting from 
the cold and damp and fog of a London winter, though by 
no means unfelt by children, press with their greatest heavi- 
ness on the old and infirm, a fact which was exemplified dur- 
ing the past winter, when in one week in February, 1880, 
characterized by severe cold and peculiarly irritating fogs, 
the death-rate in London amounted at once from twenty- 
seven to forty-eight per one thousand, mainly from the 
greatl} 7 increased number of deaths among old people. A 
general diffusion of sanitary knowledge, increased temperance 
on the part of the parents, and a heightened standard of com- 
fort, may be expected to diminish very appreciably that pro- 
portion of the infant mortality which is directly due to the 
conditions of the London winters. Asa rule, indeed, children 
who are well fed, well clothed, and well housed, keep par- 
ticularly well in London during the winter. What the poor 
chiefly want to learn with regard to the winter management 
of their children is the immense value of warm clothing, and 
if the mothers had more money to spend they would soon 
learn this. The children often wear too little flannel because 
the father drinks too much beer. 

Next in importance to fresh air and the influence of tem- 
perature comes the question of food. Children urgently need 
both a suitable and abundant food supply, and we have to ask 
how their chance of getting this is affected by city life as 
compared with life in the countiy. If we are careful to con- 
trast the condition of parallel classes, and to avoid the mis- 



HOW CAN CITY CHILDREN BE KEPT HEALTHY? 9 

take of supposing that every one in the country has a cow 
and a farm-yard of his own, we shall probably come to the 
conclusion that only a small part of the extra difficulty of 
keeping town children in health can fairly be attributed to 
the inferiority of their food supply. In many cases suitable 
food for children is even more difficult to get in the country 
than in large towns. Milk, for instance, is to the poor an im- 
possible luxury in many country districts in England, and 
eggs and butter are scarcely less so. In London these are all 
within every one's reach, and though perhaps of but indiffer- 
ent quality, they are of great importance in the children's 
dietary. Variety of animal food, of vegetables and fruit, is 
also much more within the reach of the poor in towns than 
in the country. What the country gives in this direction to 
the children of the poor which the town does not give them 
is the appetite to eat abundantly, and vigorous powers of di- 
gestion and assimilation. Nutrition advances more rapidly 
in the country, not because to the poorest classes the food 
supply is better, but because the power to use it is larger and 
less fastidious. So that even from the stand-point of nutrition 
we come back to the far-reaching influence of fresh air. If 
we inquire how sanitary science in its application to town life 
could favorably affect the food supplies of children, it is easy 
to see that, though they do not as a rule die from any impos- 
sibility of getting fairly wholesome food, there are many ways 
in which it could be improved. In London the adulteration of 
milk, butter, bread, and everything else which can be adulter- 
ated, is a grievous injury both to children and to adults. Chil- 
dren, however, suffer more seriously from their parents' want 
of knowledge and judgment in the choice of food than from 
its quality, and more especially from the indolence which leads 
to feeding infants on food only suited to adults. Much has 
been done in this country to awaken the attention of mothers 
to the evils of such indolence, especially by very simple popu- 
lar lectures at mothers' meetings, and to the elder children in 
schools ; and it may be anticipated that, in time, agencies of 
this kind will do a good deal towards diminishing the evil. In 



10 HOW CAN CITY CHILDREN BE KEPT HEALTHY? ' 

a large city money could with great advantage be spent in 
supplying sanitary lecturers specially trained to deal with poor 
mothers, and to teach them, both by theory and practice, how 
to adapt the dietary of young children to their special needs, 
and how to improve the dietary of the adults of their family. 
The object would probably best be attained by employing 
people of the class of Bible-women, or district or parish nurses, 
and giving them a simple and practical training specially ad- 
dressed to this subject. No machinery is likely to be of much 
value which cannot be carried into the very homes where the 
teaching is wanted, and only women can so carry it. 

The first eighteen or twenty months of life is the time when 
suitability of food is of greatest importance, and even of this 
time the earliest months are of far more moment than the 
later ones. Nothing can make up to an infant for the want of 
its natural food during the first year of life, and wherever the 
mothers are to any considerable extent engaged in manufac- 
tories, or in work which separates them from their infants, 
the effect is sure, in a large majority of the cases, to appear 
in the debility or death of the children. It is no doubt true 
that many children of a higher social class are successfully 
reared upon artificial food, but every mother or nurse who has 
succeeded in doing this knows the amount of minute and in- 
cessant care it requires — care of a kind, indeed, which it is 
unreasonable to expect from mothers who have the entire 
work of a household to perform. Even where this vigilant 
and skilled care is given, and where in addition the infant is 
helped by every hygienic resource, the attempt to do without 
its natural food often results in failure. Some advance, how- 
ever, has been made in recent years in the study of substi- 
tutes for the mother's milk, and there seems no good reason 
why a still greater measure of success may not ultimately be 
reached. 

One main element in the difficulty of artificial feeding no 
doubt lies in the great liability to change, characteristic of 
human, as well as of other milk. Probably organic fluids ex- 
posed to air at ordinary temperatures are always changing 



HOW CAN CITY CHILDREN BE KEPT HEALTHY? 11 

more or less rapidly, and, apart from its easily recognized 
chemical difference, much of the peculiar virtue of human 
milk as food for infants may be in its freshness, in its perfect 
freedom from infective particles, nay, even in its nascent 
character. Mothers at any rate agree in thinking that infants 
neither like nor digest so well milk which has remained an 
hour or more in the breasts as they do that which is, as it 
were, manufactured expressly for them the moment it is 
wanted. It is difficult to anticipate that organic chemistry 
will ever so completely yield up its secrets as to enable us to 
understand how this subtle change is effected, or to produce a 
food at all comparable to that provided by nature. Probably 
to the end of time the real thing will be much better than 
any imitation, and some children will always refuse to thrive, 
or even to live, upon anything but their dietetic birthright. 
For those, however, who cannot avoid the risk involved in 
artificial feeding, and also for young infants when partially or 
wholly weaned, carefully prepared diet rules are, in careful 
hands, of great practical value. They need to be plain, mi- 
nute, and dogmatic. Any attempt at physiological or chemical 
explanation is sure to be misunderstood, and the rule itself is 
more likely to be remembered if presented in a dogmatic 
form. The rules should state the degree of dilution cow's 
milk requires at each age, how to prevent the formation of 
heavy curds in the process of its digestion, when to add an 
alkali, its form and quantity, when to begin the addition of 
farinaceous and animal food, and which of such kinds of food 
is best for children of each age. These are points so familiar 
to medical authorities that it would be superfluous to insert 
such rules in this paper. They can be found at once in the 
writings of Dr. Eustace Smith, Dr. J. Lewis Smith, Dr. West, 
and many others. 

A further important part of the question of the food supply 
is that which relates to the drinking water. Young children 
should no doubt not be large water drinkers. Milk is their 
natural and proper drink till they are almost out of child- 
hood. But to poor people milk is, as a rule, too costly to be 



12 HOW CAN CITY CHILDREN BE KEPT HEALTHY? 

used in this liberal fashion, and the drinking water becomes 
to them as important for their children as it is or ought to be 
for themselves. The first thing: that strikes one in thinking: 
about the drinking water in connection with the special dif- 
ficulties of city life is, that here we touch a point upon which 
town-bred children ought to have an advantage over their 
country cousins. And even with the many shortcomings 
(some of them scandalous ones) of our London system, it is 
probably true that London water is, as a rule, a less danger- 
ous drink than that at the service of the English agricultural 
population. Whether this is so or not, it cannot be doubted 
that a community is in a far better position for getting whole- 
some water than single scattered families of poor and igno- 
rant people ever can be, and that it is a grave blot upon their 
civic organization if they have not succeeded in getting it. 
A laborer's country cottage must have its water supply close 
at hand, and it must be the cheapest possible ; therefore it is 
a surface spring, and close to all the obvious sources of impu- 
rity round the house. As a rule, in England, the well and the 
cesspool, or the pig-sty, are within a few yards or feet of each 
other. In large towns there can be no real difficulty in carry- 
ing water of almost absolute purity to every house ; it is 
simply a question of expense. In London, the system breaks 
down mainly on the point of the storage of the water in the 
houses. In houses for the richer people there are cisterns, 
often dirty, and often in direct connection with the drains of 
the house. Man} 7 of the houses for the poor have no cisterns, 
but only water-casks or butts, often not covered, and rarely if 
ever cleansed. Even if the water so stored is not very poi- 
sonous, it is most unattractive. It is scarcely possible under 
these circumstances to urge water drinking with much zeal. 
Bearing in mind all the temptations to intemperance which 
surround the toiling inhabitants of the poorer parts of our 
crowded cities, the sense of exhaustion which results from in- 
door labor, from the absence of pure air and bright light, it is 
impossible to regret too deeply the way in which, even from 
childhood, the poor are forced into drinking stimulants by the 



HOW CAN CITY CHILDREN BE KEPT HEALTHY? 13 

want of wholesome and pleasant water. This, however, is a 
fault not inherent in city life, but one which results only from 
indolence, ignorance, and supineness, and will, it may be 
hoped, in time disappear. It is at any rate certain that a 
town-bred child ought to be better provided with pure water 
than poor country children are likely to be, and that the ab- 
sence of wholesome water in a city is a misfortune which need 
not and ought not to be present, and one to which we should 
not allow ourselves to become reconciled. 

The third essential condition of health in children is that 
they should have come of a healthy stock. This supplies, no 
doubt, one important factor in the comparative difficulty of 
rearing healthy children in cities. In many cases the in- 
fluences of town-life before the children were born have de- 
teriorated the health of their parents. In every crowded 
community intemperance, tuberculosis, and s} 7 philis under- 
mine the health of thousands of parents at a comparatively 
early age, and the children born of such parents cannot be 
healthy. Not, of course, that either vice or constitutional 
disease is rare in the country ; probably morals are much the 
same in a given grade of education and intelligence every- 
where, but the influences of town life tend to increase the 
temptations to vice and to aggravate its physical results. In 
some cases moreover, country life, with its fresh air and the 
stimulus this affords to all the nutritive functions, may just 
supply the child of moderately unhealthy parents with what 
it needs to enable it to revert to a higher standard of health. 
For it is necessary to bear in mind that powerful as are the 
laws of heredity, like to their parents as children are and 
must always be, there is yet in human beings under favorable 
circumstances an uncontrollable set towards health and against 
the perpetuation of disease. If it were not so, if the force of 
heredity were strong enough to be able to brand the children 
through many generations with the results of the intemper- 
ance, the vice, and the recklessness of their forefathers, who 
among us would be sane, or wholesome, or healthy ? Prob- 
ably no one could show a clean bill of health, with regard 



14 HOW CAN CITY CHILDREN BE KEPT HEALTHY? 

even to the worst diseases, for even so short a time back as 
ten or twelve generations, and what are these in the life of 
the race ? There is, for instance, no disease more truly con- 
stitutional in character, and therefore more ready to pass 
from parents to children than gout, and }^et we constantly see 
people who though coming of a gouty stock, by leading 
strictly temperate and active lives have almost completely 
freed themselves from their hereditary enemy, and who do 
not transmit it to their children so long as they also lead 
healthy lives. So that but a few generations, two, or three, 
or four, may suffice to do away with this otherwise most 
powerful hereditary taint. But no doubt it is true that the 
regenerating process, by which the race casts off gradually 
its acquired imperfections and tends to revert to the normal 
condition of health, requires both time and favoring condi- 
tions. Children are too close to their parents in point of time 
not to be very like them, flaws and all, and unless their in- 
herited flaws can be met and counteracted by wholesome in- 
fluences, the process of regeneration must be delayed, or even 
in the worse case, as is so often exemplified in the gradual in- 
tensification of nervous diseases, a downward course may be 
taken, and the constitutional type, instead of improving, will 
progressively degenerate. City life as lived by poor children 
is certainly not that which would enable them even to begin 
to throw off inherited imperfection ; and practically we find, 
and probably always shall find, a vast amount of disease or 
imperfect health due to hereditary influences which no per- 
fection of hygiene, so far as it can be applied to the town life 
of the poor, can tend greatly to diminish. 

The next important element in the question of how to keep 
city children healthy is that which relates to the prevention 
of the spread of infectious or zymotic disease. Diseases of 
this class are gravely important, not only from the very large 
number of deaths they directly cause, but also by the chronic 
debility or disease which too often results from them. This 
is a part of our subject which would amply repay the careful 
consideration of all who desire to benefit the children of a 



HOW CAN CITY CHILDREN BE KEPT HEALTHY? 15 

town, for it is one in which much good may be done, though 
the parents themselves are not in a position to do it. The 
chief hindrance, indeed, to the most important measures in 
this direction will be found in the ignorance and unen- 
lightened affection of the parents. It is of course vain to talk 
of disinfection or of precautions against the spread of disease 
while children suffering from measles, scarlet fever, small-pox, 
or whooping-cough, remain in their crowded homes. The 
only measure worth discussing is that of removing and isolat- 
ing them. If the hearty cooperation of the parents could be 
won, every child taken ill with any of these diseases in a 
crowded house ought at once to be removed to a special hos- 
pital, and adequate precautions there taken against communi- 
cating the infection. The art of disinfection is gradually be- 
coming so much better understood by professional advisers 
than it was even a short time ago, that it is not now Utopian 
to believe that were the sufferer once in skilled hands and 
isolated, the spread of these diseases from each separate case 
might be completely checked, and that by repeatedly stamp- 
ing out infectious disease in isolated cases epidemics might be 
prevented. Such a scheme as this supposes a separate hos- 
pital, or at least a completely separate block of wards for each 
of the important zymotic diseases, each having a separate staff 
of nurses, and, if possible, separate and resident medical at- 
tendants and separate administrators. It seems plain, from 
the history of the epidemics of the Middle Ages, silent traces 
of which still remain in the vast lazarettos of Milan and other 
continental towns, that diseases which were then not less 
serious scourges than scarlet fever is now, have been practi- 
cal^ stamped out by a general improvement in the sanitary 
condition of towns once decimated by them, combined with 
a rigid process of isolation whenever the diseases in question 
appeared in the community. We have become alive, within 
the last few years, to the danger of infection being spread 
wholesale, as it were, in several ways hitherto unsuspected. 
Epidemics of scarlet fever have now in several well-investi- 
gated cases been proved with almost mathematical precision 



16 HOW CAN CITY CHILDREN BE KEPT HEALTHY? 

to have been due to the milk supply having been contaminated 
with the scarlatinal poison. An instance of this, hitherto un- 
recorded, occurred in Scotland three or four years ago. A 
large boys' school at Aberdeen had part of its milk supply 
from a particular farm near by. A girl old enough to be 
of use in the dairy fell ill, and was shortly pronounced to be 
suffering from scarlatina. With commendable honesty the 
farmer sent down to the school, as soon as the girl's illness 
was recognized, to ask if the milk should still be sent. It was 
stopped, but the supply of the day before and of the same 
morning had already been used, and within thirty-six hours 
eighteen persons in the school-house were ill with scarlet 
fever, as well as several other persons in neighboring houses 
who had had milk from the same farm. 

This case was further remarkable from the fact that, so far 
as could be ascertained, the girl at the farm was the first per- 
son who had been ill there, and if so, the contagion from her 
must have been very active, even in the earlier and acute 
stage of the disease. Possibly, as suggested in reference to 
summer diarrhoea, the germs upon which contagion depend 
may find a very suitable environment in milk, and therefore 
may develop in it with unusual rapidity. A curious and un- 
explained fact about the epidemics caused or conveyed by 
milk is that the type of scarlet fever so conveyed has hitherto 
appeared always to be mild in character. Further observa- 
tion of similar cases may serve to show that this has been 
merely accidental, but it is a point worth noting for future 
observation to confirm or disprove. No one knows yet why 
some epidemics of scarlet fever are so immensely more dan- 
gerous than others, and anything which could help to a clear- 
ing up of this point might prove to be of enormous practical 
value. If we knew the conditions, whether individual or 
general, which lead to the occasional development of malig- 
nancy in the scarlatinal poison, those conditions could proba- 
bly be influenced favorably and the malignancy prevented or 
diminished. 

Whilst waiting for the time when the general good sense 



HOW CAN CITY CHILDREN BE KEPT HEALTHY? 17 

of the community shall make it po*ssible to isolate rigidly 
every case of infectious disease, it would be well that the 
sanitary lecturers employed among the poor in a town should 
be taught practically a few of the more efficient and available 
processes for disinfecting clothes and bedding, such as that 
which depends upon the liberation of a large quantity of 
chlorine gas. It cannot, however, be too clearly insisted 
upon that disinfection in any sense which implies safety to 
the community is an impossibility in crowded houses, and 
among poor people who cannot afford to destroy their clothes 
and other property. Only as the handmaid to isolation is 
disinfection of substantial value. An exception to this asser- 
tion might, however, perhaps be made where the disinfection 
can be applied assiduously and skilfully to the centre of con- 
tagion, that is to the sick person himself. Even in a disease 
so eminently contagious as scarlatina, cases have occurred in 
which, without attempting any isolation of the patient, no in- 
fection has been conveyed, the result having apparently been 
due to the frequent inunction of the invalid with carbolized 
oil. Among the poor, however, precautions of this class are 
sure to be very imperfectly carried out, and the real check to 
epidemics of zymotic disease must be sought in isolating every 
case as soon as possible after it has declared itself. Even 
apart from their crowded homes, the ordinary conditions of 
life to children of the poor lend themselves with unhappy 
facility to the spread of infectious disease. From early in- 
fancy large numbers of children are grouped together, in day 
and Sunday schools, in church and chapel, in playgrounds 
and in the streets. Poor children know, as a rule, no soli- 
tude. They are always in society, and usually in a very 
crowded society. Objections are occasionally urged against 
infant and other primary schools on the ground of their being 
centres of infection, and no doubt it is true that every school 
must occasionally be open to such an accusation. It appears, 
however, to be useless to grumble at the school before mak- 
ing an attempt to isolate the contagion in the home. So long 
as cases of scarlatina and other infectious disease are allowed 
2 



18 HOW CAN CITY CHILDREN BE KEPT HEALTHY? 

to remain in houses of which, perhaps, every room contains a 
family, it would be beginning at the wrong end to exercise 
any very zealous supervision over the schools. 

In addition to the prevention of epidemic disease, an intel- 
ligent guardianship of the health of town-bred children ought 
to consider to what extent it can aid in the prevention of 
various other familiar forms of disease, such as tuberculosis, 
rickets, syphilis, and nervous disease in its many forms. The 
inevitable conditions of city life — crowding, intemperance, 
vice, poverty, and struggle — render it all but certain that 
these diseases will continue common in cities, and that phil- 
anthropic efforts will not, except indirectly, greatly diminish 
the number of children injured or destroyed by them. We 
know, for instance, that the most potent weapon against the 
development of tuberculosis is abundance of open-air exer- 
cise and of good food. But we know also that to hundreds of 
the dwellers in cities abundance of either of these is out of 
the question. They have to struggle on upon the minimum 
rather than the maximum allowance of fresh air and food, 
and tuberculosis results. 

Rickets ought no doubt to be capable of being materially 
diminished wherever the general standard of intelligence and 
comfort is tolerably high among the working people of a city. 
It is a rare disease when mothers are themselves well fed, 
when they know the importance of milk in their infant's diet, 
and when they can afford to act upon their knowledge. 

The important social and political question of how to pre- 
serve children as far as possible from the terrible blight of 
hereditary syphilis is one which, though coming strictly 
within the limits of our subject, cannot well be satisfactorily 
dealt with in this place. It is enough to record its grave im- 
portance, and the responsibility which attaches itself to any 
one who does what he can to prevent legislative interference 
with the diffusion of syphilitic disease among the adult popu- 
lation. 

Very little attention has been paid hitherto to the im- 
portant subject of the prevention of nervous disease in chil- 



HOW CAN CITY CHILDREN BE KEPT HEALTHY? 19 

dren and young adults. Many of the more familiar of the so- 
called nervous diseases belong mainly to the stage of decline, 
and as for the most part people wear out at a rate roughly 
proportioned to their years, they are seen most commonly 
after the age of "fifty. But these " old age " nervous diseases, 
as they may be called, often only very accidentally belong 
to the nervous system. The real fault is, as a rule, in the 
nutrition of the small arteries, in the condition of the valves 
of the heart, in the undue development of connective tissue 
everywhere, or in the kidneys and other leading organs. 
Faults of these various kinds manifest themselves through the 
nervous system by the injury they inflict upon it ; for example, 
the rupture or the embolic closure of a vessel interferes with 
the nutrition, or destroys the integrity of certain cells or fibres 
of nervous tissue, and thus indirectly interferes with nervous 
function. Similarly, syphilitic nervous disease (so-called) 
rarely starts from true nerve-tissue, though it makes itself 
manifest by its influence on this tissue. It is not the fault of 
the nervous cells and fibres that they cease to work when 
starved by the blocking of their nutritive blood-vessel, or 
when ripped up by a clot of blood, or when squeezed out of 
life by a syphilitic deposit. Nor is it these indirect results 
of disease elsewhere to which preventive medicine should 
chiefly turn its attention, but to those conditions of faulty 
working of the nervous system itself to which the name of 
nervous disease properly and strictly belongs. Many of these 
conditions are common in childhood and young adult life, and 
are capable of being influenced for good, or of being deepened 
and intensified by external influences. 

What is meant, or implied, exactly by the term " functional 
nervous disease," can only be fully understood by those who 
are in possession of a clear and adequate conception of the 
position and purposes of the nervous system in the human or- 
ganization. It is necessary to realize that this system controls 
not only all mental processes and sensation and voluntary 
motion, but also the functions of organic life, the action of 
every organ, the formation of every secretion, and the size 



20 HOW CAN CITY CHILDREN BE KEPT HEALTHY? 

of every blood-vessel. All these purposes are accomplished 
by the aid of a something which we call " nervous force," and 
which we know is developed or made in the nerve ganglia 
and distributed by the nerve fibres, very much as the force 
which we call " electricity " is made in a battery and carried 
by the conductors. The ideal of nervous health is found in 
a well sustained and stable equilibrium between the work 
which the organism, as a whole and in all its several parts, 
has to perform, and in the equable production and diffusion 
of the force by which the work is performed. Wherever 
either the demand for nervous force is in excess of the power 
of manufacturing it in the nervous ganglia, or where the pro- 
duction of the force is naturally greatly in excess of the outlet 
provided for it, or where the several nervous centres work ir- 
regularly and inharmoniously, or upon too slight a stimulus, 
there we have departure from the ideal, and we are in the 
presence of nervous disorder. What we want is, that the 
work to be done and the force to do it should balance each 
other, and that the production and distribution of force 
should go on smoothly and evenly, and in response only to 
the normal stimuli. A very large part of the total amount 
of functional nervous disease is due to a fatal want of propor- 
tion between the demand for force and the power of pro- 
ducing it. People either want more force than they are able 
easily to make, and thus are stimulated or urged into efforts 
beyond their powers, or they have more than they can em- 
ploy, and they are allowed to fret their hearts out for the 
want of something upon which to spend it. It is as if a bat- 
tery of small size and few cells were expected to produce as 
much electricity as one twice its size, or, on the other hand, 
as if the current generated were stored under a condition of 
continually increasing tension. 

It is too often overlooked that people differ from each other 
as much in their physiological as in their material wealth. 
While one has an income so assured and so large that his 
only duty in relation to it is to spend wisely and liberally, 
and to invest usefully, another has to struggle daily and 



HOW CAN CITY CHILDREN BE KEPT HEALTHY? 21 

weekly to meet the necessities of the moment ; his power of 
earning being small, he has to minimize expenditure and even 
to descend to the most petty economies to make his scanty 
pittance of an income supply the barest necessaries of life. 
In the same way there are people who seem to possess almost 
unlimited stores of nervous force ; let them spend their 
strength as they will (and some of them spend it with prod- 
igal lavishness in several ways at once), they cannot come to 
an end of their resources, and even when, for the moment, 
they are worn out and weary, they can count upon picking 
up again with extraordinary rapidity. On the other hand, 
there are people whose life is a long struggle against absolute 
physiological bankruptcy. They seem never to have quite 
enough nervous force, even for a routine life, and any un- 
usual demand does for them entirely. Effort is not impossible 
to them ; sometimes, under the stimulus of emulation or anx- 
iety, they can even sustain an effort for some little time, but 
presently, when the stimulus ceases, they drop exhausted, and 
then take months or years to recuperate. 

Happily, it is exceptional to see this condition in a marked 
degree persist through mature life, but it is by no means very 
rare to see it while growth and development are imposing 
their special taxes on the constitutional powers. Assuredly it 
is most unsafe to assume that all young people may, without 
danger, be urged to make the utmost effort in their power, or 
that stimulants of various kinds, emulation, prizes, even al- 
cohol, may be used in order to elicit all the force they have 
without hesitation and without risk. The true remedy for 
insolvency is retrenchment, and what physiological paupers 
need is not stimulus, but rest and the least possible demand 
for such strength as they have. It is especially in towns, 
where children and young people are surrounded by influences 
at once debilitatino; and stimulating, that the danger of over- 
taxing and therefore exhausting the centres which manufact- 
ure nervous force needs to be remembered. In the country 
the opposite risk, that of supplying no adequate outlet for the 
nervous force when developed, is perhaps more frequently 



22 HOW CAN CITY CHILDREN BE KEPT HEALTHY? 

present, but even there this is a danger which belongs prop- 
erly to a later age. In considering how the special draw- 
backs of city life can best be dealt with, we have to ask, from 
the point of view of the people badly off for nervous force, 
how all the recreative and recuperating influences can be in- 
creased and the stimulating influences be diminished. The 
first part of the question is answered by improving the general 
hygienic condition, providing good air, open spaces, easy access 
to the country, simple nutritious food, and facilities for plenty 
of bathing, etc. The second part of the question, however, is 
a more complex matter. It is not easy to see how the life of 
a great city can ever be made unstimulating, or how the in- 
terests of the weak can, in city life, be specially considered. 
For it must be borne in mind that the stimulus of competition, 
of rival effort, and of constant variety, which belongs to town 
life, just suits the strong, and that it is they and not the weak 
ones who, in a community, will always rule. Therefore, so 
far as the adult population goes, there would seem to be but 
little possibility of materially modifying city life to suit the 
people of feeble nervous power. It must always be too keen 
and rapid to be really suitable for them. But for children, 
the difficulty is not quite equally great. Wise parents can do 
something, even among the poor, in the direction of promot- 
ing rest and long hours of sleep, of discouraging violent and 
unusual efforts, of avoiding all forms of stimulation, and espe- 
ially by not placing the child in a position involving anxious 
effort and strain. The emulation of school life is often blamed 
for nervous and other weakness in children, and it seems im- 
possible to doubt that to some it must inevitably be injurious. 
Here again, however, we have to accept the fact that in a 
community arrangements have to be made mainly to suit the 
fairly strong and vigorous, and not the exceptionally weak. 
Emulation and the stimulus it provides are great advantages 
to vigorous people, and in strict moderation they do no harm, 
even to the young, when they are strong. Primary education 
in public schools needs the help of some amount of emulation 
and competition, but even for the strong the danger of over- 



HOW CAX CITY CHILDREN BE KEPT HEALTHY? 23 

stimulation should be recognized. All that can be done in the 
way of specially protecting the exceptionally weak is that 
parents and heads of schools should recognize that there is an 
important minority of both boys and girls who are not equal 
to making any severe and continuous effort, to whom the 
stimulus of competition is positively injurious, and who re- 
quire all, or almost all, the nervous force they can supply to 
meet the requirements of growth and development. It is, 
perhaps, too much the fashion to think of children, boys and 
girls, as if they were physically almost exactly like adults, 
only a few sizes smaller and proportionally less strong. From 
the point of view of the nervous system, at any rate, this 
view is certainly unsound. It overlooks the fact that during 
growth and development the nervous centres are themselves 
in a developing condition, learning to work together in re- 
sponse to certain stimuli, and in a certain subordination one 
to another. The machine is still in process of construction 
instead of being ready for use. It is not merely not so strong 
as a larger machine, it is not yet out of the workshop in which 
it is being made. 

We meet with this fact again under a slightly different as- 
pect when we turn to the consideration of the last of the es- 
sentials of health for children already enumerated, namely, a 
watchful care during their infancy and early childhood. It be- 
comes very plain to any one who is able to consider and duly 
weigh familiar facts that by the very nature of their organ- 
ization, children, even when healthy, are indefinitely more deli- 
cate, that is, more easily upset, than ordinarily healthy adults. 
They are more mobile, their physiological equilibrium is more 
unstable, and they suffer more quickly for any violation of 
physiological or hygienic laws. The processes of growth and 
development are making enormous demands upon their nutri- 
tive powers ; they want for immediate use all the blood and 
nervous force that their blood-making organs and their nervous 
ganglia can supply them with, and the least check in either 
process threatens them with bankruptcy. To live from hand 
to mouth, as it were, each day by the help of good food, fresh 



24 HOW CAN CITY CHILDREN BE KEPT HEALTHY? 

air, and good digestion, just contriving to meet the demands 
made upon their vital powers, is with them the rule, and not, 
as with adults, the condition of the exceptionally feeble. 

It is not surprising, therefore, that slight departures from 
health, and especially those which interfere with the due per- 
formance of the nutritive processes, tell immediately upon a 
child's health and vigor. Observant eyes can see at once 
that the manufacture of good red corpuscles has been checked 
with every slight disturbance of a child's digestive or as- 
similative powers. Moreover, besides resenting hindrances 
to nutrition more than adults, they are far more prone to the 
occurrence of such hindrances. For instance, every mucous 
tract in a child is more liable to catarrh than the correspond- 
ing mucous membrane in adults. Notice how children suffer 
at once, and certainly, in their nasal and respiratory mucous 
membranes on coming from fresh pure air to the air of towns. 
It is a matter of common nursery observation that children on 
returning from a stay in the country always have pretty bad 
catarrhs within a week or so of their beginning to breathe the 
less pure air. Mothers are too well alive to this risk to forget 
it, and it certainly cannot in most cases be explained by 
" taking cold on the journey " or by want of care in any other 
direction. It is most unusual to see children take cold when 
they go from the city to the country, even at a colder season. 
The " coming home cold " is almost certainly due to the ir- 
ritation of delicate mucous membranes by an air laden with 
smoke and other products of imperfect combustion. A cor- 
responding susceptibility exists in the intestinal mucous tract. 
If, then, children are peculiarly prone both to disturbance of 
function and to the evil resulting from such disturbance, it is 
not to be wondered at that minute care is wanted to keep 
them in health till they acquire greater stability and more 
vigorous powers of resistance. When in addition to the del- 
icacy common to all children there is superadded the immense 
drawback involved in trying to rear them from early infancy 
without their natural food, it becomes impossible to exag- 
gerate the amount of care required if a successful result is de- 



HOW CAN CITY CHILDREN BE KEPT HEALTHY? 25 

sired. The only thing which can at all make it possible to 
minimize the care needed is fresh country air, and with it 
one does occasionally see thriving vigorous children, to whom 
almost every other advantage has been wanting. But for 
town-bred infants care is an indispensable condition of health, 
and care of a kind far more minute and constant than can he 
given in any creche or public nursery, or to any child put out 
to nurse for a few shillings a week. Where from any cause 
this minute and personal mother's care cannot be given, a 
large proportion of the children are bound to die, in spite of 
anything which may be done for them by outside agencies. 

It is evident, from all that has been said in considering the 
difficulties town-bred children have, to contend with, that the 
labor involved in any considerable attempt to improve their 
condition must be great, and also that it is impossible, what- 
ever may be done in this direction, ever to make town children 
as healthy as country ones. Much that may be attempted to 
diminish the dangers of city life has already been hinted at ; 
as, for example, the multiplication of open spaces in towns, a 
proper system of drainage, and an abundant supply of good 
water. For young children, however, the most important 
remedy is that of encouraging their parents to get out of the 
town, or at any rate into the suburbs. Ever}^ facility that 
can be given to the poor to live a little distance from the most 
densely populated part of a town is of the greatest value to 
the children. Where land is abundant and cheap, the posses- 
sion of a small garden even without a house, out of the town, 
would, by supplying out-door employment, be most valuable 
to both parents and children, especially to people above the 
poorest class, as, for instance, artisans and small traders. 

Passing to the subject of a summer sanitarium for city chil- 
dren, a great many important practical questions at once arise. 
Any one familiar with children cannot think with entire sat- 
isfaction of any plan which involves separating them from 
their parents, and massing large numbers of them together. 
It may be feared that such a plan must be fraught with 



26 HOW CAN CITY CHILDREN BE KEPT HEALTHY? 

danger to both health and morals : to health, if the children 
are intended to be very young, that is under four or five ; and 
to morals, if they are intended to range between five and four- 
teen. The ideal summer outing for children is that each fam- 
ily should move from the city, but should preserve the con- 
tinuity of its family life. This is impossible of attainment 
among the poor, but possibly some nearer approach to it 
might be reached than by massing together several hundred 
young children in any way which would preclude the possibility 
of giving them individual care. The boarding-out principle, 
which, so far at least as the children are concerned, works so 
well in England for the pauper children, might perhaps be 
adopted with modifications in the place of having one large 
building and grouping the children together. If a consider- 
able number of people living in healthy country localities 
were registered as being each willing to receive during the 
summer one or two town children as boarders at a fixed rate, 
and a system of supervision were organized, such a plan would 
certainly be more natural and home-like, and therefore more 
acceptable to both parents and children, than a large central 
sanitarium could ever be. Children thus placed would also 
be much more easily provided with employment and amuse- 
ment than they would be in an institution containing a very 
large number. They would enter into the duties and pleas- 
ures of the family with whom they boarded, and would feel 
themselves to be in surroundings not too unlike those in their 
own homes. 

Where such a plan as this might, from the scanty country 
population or the bad sanitary condition of the country cot- 
tages, be impractible, it might be possible to arrange the sani- 
tarium upon the plan of a number of detached houses, each to 
contain eight or ten children, and each to be under the direct 
care of one nurse or matron. By either of these methods the 
children would be secured an amount of personal and individ- 
ual care and watching which it is impossible to get from the 
hard-worked staff of an immense institution. The routine, the 
formality, and even the noise, which are necessary parts of a 



HOW CAN CITY CHILDREN BE KEPT HEALTHY ? 27 

large assemblage of children, are in themselves for a time 
trying to the health of those used to a free home life ; and 
among American children, where by climatic and hereditary 
influences the tendency is towards undue restlessness and irri- 
tability of nerves, they would be more likely to do harm than 
in a more phlegmatic or stolid community. Town children 
everywhere, and perhaps American town children more than 
any others, are as a rule much more precocious than country 
children ; mentally and physically they develop more rapidly, 
and what they need to make a change from city life of the 
greatest use to them is not the stimulation that goes with 
numbers, but the quietness and repose which belongs to coun- 
try life as seen in a small family. Fresh air, the absence of 
noise, and comparative solitude, form the basis of such a life ; 
and the combination of the three is probably as wholesome 
and recuperative to children as it is to adults. By many the 
stress of town life is felt more in the nervous system than in 
any other part of the organization; and to them especially one 
most important part of the value of a change to the country 
lies in the comparative quietness and solitude which it is pos- 
sible to have there, but which would be practically destroyed 
for the inmates of a large sanitarium. If now in conclusion 
we turn back to the question with which we started, and ask 
ourselves again how can town children be kept healthy, we 
are obliged regretfully to admit, that after public and domes- 
tic hygiene has done its best, city life will always be full of 
special risks to the children of the poor, and that philanthropic 
effort cannot do very much directly towards diminishing those 
risks. It can do something, but it must be mainly through 
the parents, by improving their knowledge of what the chil- 
dren need, by raising their standard of comfort, and by deep- 
ening their sense of responsibility. 



THE MORTALITY OF YOUNG CHILDREN: ITS 
CAUSES AND PREVENTION. 

BY SAMUEL C. BUSEY, M. D., 

Washington, D. C. 

Gentlemen of the Boabd of Trustees, — The letter 
of Mr. Francis T. King, of December 20, 1879, requests my 
advice in regard to the best method of executing the trust 
committed to the management and supervision of himself 
and others by the late Thomas Wilson, of the city of Balti- 
more. 

In 1875 Mr. Wilson founded, under the provisions of the 
Maryland Code of Public General Laws, an institution known 
as " The Thomas Wilson Sanitarium for Children of Balti- 
more City, for the purpose of securing a summer retreat for 
sick children from the heat and unhealthfulness of the city, 
and for such other kindred purposes as may be hereafter de- 
termined upon by the corporation." 

In his will, executed in February, 1879, the testator declares 
his purpose in making the bequest of five hundred thousand 
dollars to the institution to be " the alleviation of the pains, 
and the prolongation of the lives, of children." In the same 
sentence of this last will and testament occurs the expression 
of his pity " for the suffering of little children and their par- 
ents," and of his deep concern and sorrow " at the great and 
alarming mortality which occurs each summer among young 
children." 

How best to execute such a trust is a grave and complex 
question. A final and satisfactory conclusion can only be 
reached after a careful and mature consideration of the causes 
and means of prevention of the diseases and mortality of early 
life. Those who are to become the beneficiaries of this char- 



THE MORTALITY OF YOUNG CHILDREN. 29 

ity are denominated by its founder "young children, deprived, 
by misfortune of their parents, of all opportunity for removal 
from the heated and fatal atmosphere of the city," and by the 
charter title of the institution "children of Baltimore city." 
Hence to fully grasp the proposition thus distinctly and suc- 
cinctly set forth, the various agencies and elements of causes 
conducive to the mortality of early life, must be considered 
with special reference to the density, ignorance, poverty, and 
indigence of the population of Baltimore, together with their 
hygienic and domiciliary surroundings. 

Age is the first and essential factor in this complex assem- 
blage of causes. Childhood properly comprises the period of 
human life from birth to puberty, but for convenience of sci- 
entific study, and to secure accuracy of the statistics of the 
comparative morbility and mortality of the successive stages 
of growth, it has been subdivided into four periods which are 
characterized by developmental processes. The first period 
extends from birth to the appearance of the first tooth (fifth to 
tenth month) ; the second from the beginning to the comple- 
tion of the first dentition (twenty-fourth to thirtieth month) ; 
the third from the termination of the first to the completion 
of the second dentition (sixth to seventh year) ; and the 
fourth from the second dentition to puberty (twelfth to fif- 
teenth year). These successive periods must be studied with 
reference to the probability of sickness, their comparative 
mortality, and their liability to special morbid conditions. 

In view of the clearly defined purpose of the founder to af- 
ford opportunity for the removal of young children from the 
"heated and fatal atmosphere of the city," and of the fact 
that even with such a liberal endowment it will be impossible 
for the institution to supply accommodations, care, and food 
for all of the young children of the needy and squalid in a 
city of three hundred and thirty thousand inhabitants, and in- 
creasing in population as rapidly as the city of Baltimore, the 
management will be compelled at the beginning, or very early 
in the history of the institution, to determine the admissions 



30 THE MORTALITY OF YOUNG CHILDREN. 

by limitation of age, or to regulate them by some well-defined 
system of individual selection. The first will prove to be the 
more practicable and efficient method, though it may be wise 
to reserve the privilege of selection to meet occasional in- 
stances of exceptional need. The completion and occupancy 
of the Johns Hopkins Hospital will probably limit the number 
of applications of sick children beyond five years of age to the 
very few who may be unfit subjects for hospital treatment, 
and yet require the invigorating and healthful influences of 
a salubrious atmosphere. A few years of experience in con- 
ducting the institution and the determination of the actual 
daily average cost per capita for maintenance will furnish 
the requisite data for the final adjustment of the later age of 
admission, but the earlier age should be fixed before the ac- 
ceptance of any plan for the construction of the necessary 
buildings. 

The determination of the age of exclusion must, however, 
be considered with special reference to the two classes into 
which the beneficiaries will be divided. For convenience these 
may be denominated the visiting and domiciliary classes. The 
first and larger class will be composed of those children who 
will be offered a refuge from the city during the day, return- 
ing again at night-fall. Even if permissible, it would be un- 
wise to extend this privilege to all the needy and indigent 
children under the age of puberty. A limitation of age will 
be imperatively demanded, because of the inadequacy of the 
endowment fund to meet such an extraordinary outlay, and 
the impracticability, if not impossibility, of conducting an in- 
stitution to which would resort daily such a concourse of juve- 
nile excursionists, including the invalid, sick, hungry, idle, 
vicious, abandoned, truant, and mendicant, of both sexes, of 
all colors and nationalities, and all ages under the prescribed 
limit, together with the mothers or necessary attendants of 
the younger children. 1 A system of daily excursions during 

1 The Floating Hospital of St. John's Guild, of the city of New York, 
made thirty-five excursions, " between the 9th of July and 6th of Septem- 



THE MORTALITY OF YOUNG CHILDREN. 31 

the summer months, if properly organized and managed, 
might prove of great advantage, both in its lessons of moral 
training and opportunities for physical development. The 
advantages of this department should be offered to the largest 
number compatible with good order and the welfare of the 
young. Transportation, accommodations, food, water, shelter, 
shade, amusement, and protection must be adequate to the ex- 
igencies of the excursions, the number and personnel of which 
would vary daily, according to the popularity of the institu- 
tion and the necessities of the children who might be entitled 
to the benefits of the sanitarium. 

But even with all such necessary facilities and with proper 
appurtenances as a place of daily resort for children, the or- 
ganization of a system of excursions as a means of promoting 
health will fail of success unless the confidence of the commu- 
nity is assured by efficient and expert management. Safety, 
security, and positive benefit must be made apparent to that 
class of parents and guardians with whom theoretical asser- 
tions and predictions of possible advantages will have but 
little weight in diverting them from their long accustomed 
routine of life. Their habits, education, poverty, family his- 
tory, superstition, and proverbial indifference to the welfare 
of children, lead them into obstinate antagonism towards 
every so-called encroachment upon their long conceded owner- 
ship of the body and control of the life of the child. The 
evidences under their immediate observation that neighboring 
children have grown to vigorous maturity without such ex- 
traneous aids as charitable excursions to country play houses 
and grounds may offer are, in the absence of proof of positive 
personal gain, arguments far more conclusive than any fact 
deduced from mortality statistics. They accept the occur- 
rences of life as they see them, soon forgetting the past and 
incredulous of evils to come. Life is completed with each 

ber, 1879, and carried 27,818 children and mothers, being an average of 
794A on each excursion, in the proportion of about 2^- children for each 
adult." (Extract from report of 1880.) 



32 THE MORTALITY OF YOUNG CHILDREN.] 

day's existence. To-morrow may be but the repetition of to- 
day, and each successive day's life deepens the oblivion of 
things gone before, and fastens more firmly upon the life of 
the future the errors of the past. The false interpretation of 
one's own observation of matters concerning the preservation 
of health and the cause, prevention, and cure of disease is a 
fruitful source of error common to all classes of laymen, and 
is a special characteristic of the ignorant, indigent, idle and 
laboring classes. They resist, and often resent with threaten- 
ing ferocity, every innovation upon the established customs, 
habits, and conditions of their life and domicile. 

Considerations of domestic economy and convenience will 
also enter largely into the antagonisms of these communal 
classes. The ownership of the body will assert its preroga- 
tive on the pretence of valuable assistance of the child in the 
trivial concerns of the family household. An idle and de- 
bauched father will not willingly relinquish, even for a day, 
the enslavement of a helpless son or daughter, and an incon- 
siderate mother will cherish the authority which commands 
the little girl to sit or go, watch or work, while she either 
fritters away time in idle discontent, or slovenly performs some 
of the duties of the day. The older must care for the younger 
child, or run on errands. The pretence of authority, assist- 
ance of a child, tender affection of a mother, parental care, 
or fear of harm, will be interposed as an obstacle to the ab- 
sence of the child from parental observation and control. The 
pleasures and pastimes of a health resort offer no inducements 
to parents so stolidly indifferent to the comfort and well-being 
of children. 

Another class of parents, whilst professing deep concern for 
the health and welfare of the little ones, will clandestinely 
connive at means which will relieve them of their burdens 
under the guise of disease. They are mostly husbandless 
mothers who are compelled or wish to engage in employment 
away from their homes, or who follow vicious habits, and 
whose inclinations are too frequently interrupted by, or whose 



THE MORTALITY OF YOUNG CHILDREN. 33 

scanty earnings are too heavily encumbered with, the proper 
support of the child. They will offer many and divers ex- 
cuses for their cruel neglect, and refusal to surrender the con- 
trol of the sick and suffering child to competent and intelli- 
gent management, but will gladly accept the brutal care of 
the keepers of the iniquitous dens where " farmed out " chil- 
dren are slowly but certainly starved to death. Many of the 
" at service " mothers are compelled either to farm out the 
infant at the breast or abandon all hope of obtaining decent 
employment, because so many housekeepers will not permit 
a child to accompany the cook or housemaid. The responsi- 
bility for such cruelty to helpless children cannot be charged 
solely to the unfortunate mothers. Either this custom, which 
inflicts such punishment upon a dependent class, must be re- 
formed, or some other provision must be made for the bet- 
terment of their condition. The sanitarium will offer, in 
its visiting or domiciliary department, the additional option 
of a refuge during the summer months, and thus save to 
many good but destitute mothers the " well-spring of pleas- 
ure." 

The prejudices of caste will offer formidable obstacles to 
the early and general acceptance of the benefits of the visiting 
department. Pauperism and vice draw sharp lines of dis- 
tinction between their various grades. Misery loves company, 
and crime seeks coadjutors ; but shop-lifting and burglary are 
as widely apart in their social relations as industry is from 
insolent mendicancy. The largest portion of the poorer 
classes of every municipality are far removed in social and 
moral standing and interests from the pauper and vicious 
classes, and very many of the most destitute maintain the 
dignity of exclusive associations. Poverty and pride are not 
infrequently united and hereditary, and are as obdurate in ad- 
herence to the prestige of name and family as they are pro- 
nounced in their contempt for their neighbors of plebeian ori- 
gin. The different creeds and trades often organize among 
the laboring and "hand to mouth " classes fraternities even 

3 



34 THE MORTALITY OF YOUNG CHILDREN. 

more austere in their companionships than the aristocracy of 
descent or the more pretentious caste of wealth. 

In all grades of society ^ but especially in the lower walks 
of life, there are Tery many otherwise good and well mean- 
ing people who are practical fatalists, honestly believing or 
affecting to believe that the ailments of little children come 
independent of human or material agencies, and as the just 
retribution of an inscrutable Providence. The facts are al- 
ways before them that the number of living children increases 
year by year ; that many, for years puny and sickly, and 
many times sick nigh unto death, have grown, without un- 
usual care or extraneous aids, to vigorous childhood : and that 
in a neighboring habitation, in no manner superior to their 
own, there is a corporal's guard or baker's dozen of healthy, 
robust ragamuffins, whilst other more fortunate families 
have lost one by one all their children. They point with 
exultation to the inevitable truth that sickness and death in- 
vade the palaces of the affluent as well as the humble tene- 
ments of their less fortunate neighbors. In the grief of the 
sick chamber and sorrow at the bier they seek consolation in 
the exculpating wail, " It is God's will." 

It is not, however, just to charge all of these antagonisms 
exclusively to the wilful derelictions of parents and guar- 
dians. Their objections and excuses are not always mere 
imaginary pretexts, suggested by their morbid sensibilities or 
class distinctions. Neither are they offered by all to excul- 
pate themselves from the suspicion or consciousness of wrong- 
doing. In the lower grades of society there are very many 
deserving people, as good as the} 7 know how to be, who 
strive to earn an honest and decent livelihood and supply 
their little ones with all the comforts their meagre resources 
will allow. They would accept with alacrity the privileges 
and benefits of a gratuitous daily health picnic for them but 
for the unavoidable sacrifice of time and the interruption of 
their accustomed employment. The rigorous demands of 
task-masters and the employing classes will not tolerate the 
tardy performance of allotted work. The widowed mother, 



THE MORTALITY OF YOUNG CHILDREN. 85 

whose hard-earned daily pittances are barely sufficient to 
supply food, shelter, and clothing for her dependent family, 
cannot remit a day from the routine of poorly paid labor ;'nor 
can the wife, whose husband must strike the anvil or drive 
the jack-plane at the tap of the bell, absent herself from her 
inexorable duties. Such people cannot defer the work of the 
hour without loss of time and money. The prospective ad- 
vantages of the sanitarium will not liquidate their current 
expenses. Time and ability to labor constitute their only 
capital. The additional expense, trifling as it may seem, of 
getting the children ready for the excursions and going to 
and from the places of departure, will prove a burden too 
onerous for them to bear. 

Cleanliness and decent protection of the person of each ex- 
cursionist must be required. To huddle together in convey- 
ances half nude and filthy children gathered indiscriminately 
from the beneficiary classes, and transport them to a pleasure 
ground for the benefit of health and physical improvement, 
would be a waste of means and effort, and an idle pretence 
and show of charity. To commingle the clean and the dirty 
would be repugnant to the instincts of humanity, and detri- 
mental to the welfare of the better portion. The common 
sayings that water is as cheap as dirt, and air is free to 
all, are not universally true. To the dwellers in the filthy, 
over-crowded, and ill-ventilated tenements of man}' localities 
in populous cities, pure and fresh air is unknown, and water 
is insufficiently supplied even for the most necessary use. 
Among the indigent families there are some so destitute of 
the ordinary and necessary implements of housewifery that 
even an abundant supply brought to their doors would be 
unavailable. Some are too poor to be clean, and others too 
ignorant to know the uses of water beyond the demands of a 
brutal instinct. 

The enforcement of the requirement of personal cleanli- 
ness and decency would not only deny to many well-meaning 
and meritorious parents the privileges of the institution, but 
would exclude very many children most in need of the moral 



36 THE MORTALITY OF YOUNG CHILDREN. 

restraints and salutary influences of the health resort. Its 
omission would be culpable negligence. Filth, dirty rags, and 
foul exhalations from unclean bodies are carriers and propa- 
gators of disease. With such disgusting accompaniments the 
daily concourse of visitors would be an excursion of fomites 
and animal parasites. 

A large percentage of the mortality of early life is due to 
the contagious diseases which comparatively few children es- 
cape. These diseases owe their origin to specific poisons 
which are the same to-day they were when first recognized as 
separate and distinct entities, each being capable of reproduc- 
ing itself in every susceptible person. The recurring epi- 
demics usually owe their wide-spread prevalence in towns and 
cities to the assembling together children from infected locali- 
ties or dwelling with those from other parts which would 
otherwise have escaped. The virulence of the disease always 
bears a relation to the amount and intensity of the poison 
absorbed, and the power of resistance possessed by the sub- 
ject, but may be greatly increased by accessory agencies, or 
diminished by efficient sanitation and personal care. Long 
experience and observation have demonstrated that every 
new case of any one of these diseases is the same disease re- 
produced in another person, to whom the specific poison has 
been conveyed either by contact or by atmospheric communi- 
cation. By dilution of the poisons, isolation of the sick and 
convalescent, and disinfection of clothing, bedding, and dwell- 
ings these diseases are greatly lessened in prevalence and in- 
tensity. In fact if the same interest and concern which are 
exhibited in the monetary and business affairs of every-day 
life were wisely and intelligently employed, these diseases 
might be eradicated, and the lives of thousands and tens of 
thousands of children be annually saved. 

The children of no class, condition of life, or locality are ex- 
empt from these contagions ; nevertheless the prevalence of 
the diseases, the dangers of complications and consequences, 
and the mortality therefrom may be greatly lessened by good 
hygiene, sparseness of population, isolation, disinfection, proper 



TEE MORTALITY OF YOUNG CHILDREN. 37 

and well ventilated apartments, personal and domiciliary 
cleanliness, suitable diet, and intelligent nursing. In view of 
these facts it will become the duty of the sanitarium, which 
seeks to prevent disease, promote health, and prolong life, to 
ascertain that the children which it may assemble together in 
its daily excursions are free from infection. Fortunately the 
young children not exceeding two years of age, who will com- 
pose the large number of the beneficiaries, are less susceptible 
to these diseases than those between two and five years old, 
and the season of the year during which the institution will be 
in operation includes those months during which these infec- 
tious maladies are less prevalent and usually less virulent. This 
latter fact is an instructive and practical corroboration of the 
previous statement, that the intensity of these poisons is di- 
minished by their dilution, and by the improved ventilation 
of the dwellings and apartments incident to the warmer tem- 
perature, lesser crowding, and less constant occupancy. The 
relatively undeveloped susceptibility of infants must not, how- 
ever, be accepted as an absolute protection from possible dis- 
semination of the poisons when infants from infected dwellings 
are brought into close association with others from uninfected 
localities, for the clothing, especially when made of woollen 
fabrics, is perhaps as often the carrier of the germs of disease 
as the person of the wearer. 

The foregoing are some of the more common and serious 
hindrances which will embarrass the establishment and suc- 
cessful working of a visiting department. Will its utility as a 
health-preserving and life-saving charity compensate for the 
disappointments, vexations, and expense ? The theoretical 
humanitarian would insist that such considerations should not 
interpose insurmountable obstacles, but that a good intention, 
when persistently pursued, will always open a way to success. 
In a practical age like the present, philanthropy, like the busi- 
ness affairs of life, will be measured by the balance between 
the credit and debit sides of the account. Even if the man- 
agement should not recognize a failure and should blindly and 
persistently follow the hope of success, those who would claim 



38 THE MORTALITY OF YOUNG CHILDREN. 

an interest in its practical benefits would soon clamor for these 
benefits. To offer its privileges to every claimant, with daily 
changes of personnel, would result in an evanescent popu- 
larity, soon followed by discontent. For a time the excursions 
would be popular festivals, but pleasure without vice, profit, 
or some good or bad motive, does not seek frequent repetition. 
Soon the elements of antagonism would begin to develop, and 
discreditable confusion and turmoil ensue. The argument in 
its favor which will appeal with most force to the parents and 
custodians of the little children will be the proof of actual 
gain. As a method of preventing or a means of curing disease, 
has a monthly, a weekly, or a daily excursion to a health re- 
sort any money value ? If so, will it compensate for the loss of 
time, and the inconveniences and sacrifices imposed ? These 
considerations will present themselves as soon as the novelty 
and excitement of the gala days have ceased to interest and 
attract a class of people rudely practical in matters of stern 
necessity, but soon tiring of the aesthetic and more formal di- 
gressions from the habitual course of life. As a rule, the in- 
appreciable benefit of a single excursion, or one a month for 
each of the three, or at most four months, to a sick or inva- 
lid child, will not be observably increased by two or three a 
month or one a week, during the same period. Yet it must 
be admitted that in occasional cases of the summer diseases of 
young children the turning point of the disease dates from a 
day or night of cooler temperature, a drive in the open air 
during the cool and shadowy evening or early morning, a 
day's sojourn in a salubrious locality, or a voyage by steam or 
sail. In fact, other circumstances far less important, but in- 
volving some trivial change in a day's sick report, such as 
more efficient nursing or more careful feeding have seemed, 
at times, to have enabled an ebbing life to elude the chase of 
death. No observant physician will deny the health-preserv- 
ing and health-restoring influence of tri-weekly, much less of 
daily excursions of little children exposed to the causes of, or 
sick from the intestinal diseases so prevalent in cities during 
the summer months. Few children die of these diseases be- 



THE MORTALITY OF YOUNG CHILDREN. 39 

fore they are consumed. Life feeds as long as there remains 
food to supply its demands. Inanition and exhaustion are 
the ominous harbingers of death. Waste must be supplied ; 
assimilable aliment must be furnished, nutrition must be 
restored. Instead of bringing the milk skimmed, jostled, 
churned, watered, or otherwise injured, to the child, carry the 
patient to the cow, to the country ; not to the scantily supplied 
and crowd-poisoned village or roadside boarding-house, but 
to the farm where milk, pure and fresh, and air rich in oxy- 
gen and free from putrid exhalations, can be obtained. Even 
the air of the streets and of the open and shady parks is pref- 
erable to the atmosphere of the foul and stinking lodging-room. 
The writer has thought, not without some show of reason, 
that carrying the child through the streets, washed and dressed 
for exhibition, to a dispensary building, is not wholly without 
curative power, and that the cleanly and properly clothed 
were more amenable to remedial agencies. To express in a 
few words both the method of prevention and surest plan of 
cure is to say, Remove the child away from the city, away 
from the immediate and accessory causes ; restore and main- 
tain nutrition ; and supply suitable food. 

Whilst conceding in occasional cases the possible good of 
several, and even a single excursion, with the necessary ad- 
juncts of personal cleanliness, suitable diet, proper care, and 
skilled supervision, there cannot remain a doubt of the sana- 
tive and curative value of successive daily excursions for chil- 
dren who have not completed the first dentition, which com- 
prises the periods 1 of childhood to which the summer intesti- 
nal and alimentary disturbances are mostly confined and from 
which the largest percentage of mortality annually results. 
In a large and populous cit} 7 there will occur many cases of 
bowel and wasting diseases among older children, which will 

1 Of 297 cases of the " summer complaints " of children treated in the 
out-door department of the Children's Hospital of the District of Columbia, 
127 were under one year of age ; 83 between one and two years ; 53 be- 
tween two and three; 22 between three and four; and 12 between four 
and five years of age. 



40 THE MORTALITY OF YOUNG CHILDREN. 

appeal for succor, and to whom a day's or week's gbod sanita- 
tion and wholesome diet ought not to be denied. To this de- 
partment, 1 which will be the first attempt to organize an intel- 
ligent and proper system of health excursions as a method of 
prevention and treatment of certain infantile maladies, the 
good or bad results of which will so much depend upon its 
wise or unwise management, it will not, at least in the begin- 
ning, be conducive to its success to limit the admission by 
any rule of age which will exclude any child to whom it might 
prove to be the essential and otherwise inaccessible remedy. 
The character of the charity, the nature of the diseases in- 
cident to the season during which it will be in operation, and 
the circumstances of life of its beneficiaries, suggest the rule 
of arbitrary selection by skilled and experienced discretion, 
preference being given to those whose condition demands im- 
mediate amelioration, and the privilege to continue as long 
as the same supervision may deem it needful and beneficial. 
Then, to secure a success commensurate with the most com- 
mendable effort, the visitors should be divided into daily, 
tri-weekly and occasional classes. Experience and practical 
observation will soon determine the relative remedial and san- 
ative value of these subdivisions. Seven or more days in the 
life of any number of the same sick children passed in the 
salubrious atmosphere of a properly conducted health resort, 
with experienced and efficient nursing, proper feeding, clean- 
liness, and suitable clothing, must yield more speedy, decisive, 
and satisfactory results than would an equal number of days 
extended over a longer period of time by the omission of 
every second, third, fifth, or seventh day. And if the daily 
expense per capita of each class should be the same (and 

1 For several years past the St. John's Guild of the city of Xew York 
has had in operation a system of occasional excursions on a Floating Hos- 
pital, which is a most commendable charity. In the report of 1880, it is 
stated that all medical and sanitary experts who have given any attention 
to the subject concur in indorsing the value of the summer excursions in 
preserving the lives of infants. In several other cities a system somewhat 
similar has been inaugurated. But these charities are not identical with 
this institution. 



THE MORTALITY OF YOUNG CHILDREN. 41 

there is no reason why it should not), it must follow that the 
continuous system will be the most economical use of both 
money and time, and by reason of its more positive results it 
will save the greater number of lives, whilst at the same 
time increasing the number of admissions because of the less 
number of days each patient will remain on the invalid roll. 
But the saving of money must not be the main consideration 
in the management of this department. The aim should be 
to accomplish the greatest good to the greatest number. 
"Whatever may be the daily capacity of this department, the 
tri-weekly system would double the number of beneficiaries, 
but there are as good reasons why it should not be the only 
one, as there are why it should be a part of the general plan. 
To it may be transferred the convalescents from the daily 
class, and may be admitted those only slightly sick, the cases 
of relapse, and children of parents who cannot incur the in- 
conveniences and increased current expenditure of a daily 
excursion. 

To popularize the institution and establish it in the affec- 
tions of the people, the most intelligent and thoughtful dis- 
cretion will be required successfully to combat the various 
elements of antagonism. These antagonisms grow out of ig- 
norance, vice, poverty, or destitution, or some combination of 
these factors. The ignorance is not so much an incapacity 
to learn as it is the absence of instructive example and proof 
of certain benefit. These will be presented in every case of 
sickness cured, and every ill child restored to vigorous health 
will become a teacher of a school of loving parents, who will 
picture with graphic enthusiasm the good results, and exhibit 
the proof in the sturdy health of the infant. Unfortunately, 
however, deaths will occur ; and though such an event is oft- 
entimes soon forgotten by such people, because another sup- 
plies the place, or the after- coming baby soon solaces all sor- 
row ; nevertheless, every death will be an instance and proof 
of failure held in remembrance by the croakers and malcon- 
tents to be found in all grades of society and in every circle 
of acquaintance. It cannot be expected that the institution 



42 THE MORTALITY OF YOUNG CHILDREN. 

will ever be free from such unjust criticism, but as the life 
roll will' so far exceed the death roll, and each recovery will 
continuously multiply itself in an increasing ratio of recruits, 
whilst the grave will hide from view and time will efface the 
memory of each successive death, the mass of people will 
eventually, and very soon under proper management, accept 
the visible evidence of the value of the summer sanitarium. 

As a practical instructor in personal and domiciliary hy- 
giene, and the selection and preparation of aliment for and 
feeding of young children, this department should occupy a 
field hitherto neglected. Its method of teaching by the exhi- 
bition of good results and the constantly increasing number 
of children restored to health will accomplish more, and in 
less time, in the direction of preventive medicine than could 
otherwise be attained. This educational influence will not 
be limited to the beneficiary classes or confined to the city of 
Baltimore, but will be widely disseminated. As a pioneer 
institution in an enterprise so important and so closely con- 
cerning the health interests of large and densely populated 
communities, it cannot take the hazard of failure by intrust- 
ing the performance of its simplest duties to incompetent 
agents. It will probably never be possible altogether to pre- 
vent the summer intestinal ailments of young children, and 
it will be equally impossible to restore every case to health ; 
but the education of the masses in the causes, methods of pre- 
vention, and proper management and treatment in the early 
stages will diminish their frequency and vastly lessen their 
mortality. It may indeed be surmised, even before the selec- 
tion of the location or the determination of the plan of the 
necessary structures, that its most valuable contribution to the 
welfare of society and to the wealth and power of the city 
and nation will be in the instruction of the general public in 
the art of preserving the health and prolonging the lives of 
little children. 

The obstacles which poverty and destitution may interpose 
will, in a measure, be beyond the reach of any educational 
influence. Undoubtedly the general diffusion of a knowledge 



THE MORTALITY OF YOUNG CHILDREN. 43 

of the laws of health and disease will tend to diminish suffer- 
ing, want, and poverty, and in time to come the agency of 
this institution will be recognized as an important instrumen- 
tality in effecting the betterment of the condition of the pau- 
per classes. But at present it is not so much the incapacit} 7 
and unwillingness of the poor and destitute to be taught, as it 
is their inability to accept even a gratuitous benefit at the 
expense of a trivial loss of time, or a penny's addition to cur- 
rent expenses. It so happens, however, that in ever} 7 civil- 
ized community there are individuals, organizations, and soci- 
eties whose sympathies are keenly alive to the wants and 
sufferings of little children, to whom it will be necessary only 
to make known their indigence to obtain for them abundant 
supplies. The goodness of a woman's heart and the innate 
love of the sex for children will always find the ways and 
means to meet all such demands. 1 It may be accomplished 
by some organized system of discovery which will send its 
agents into the homes, alleys, and hovels where want, hunger, 
and disease are to be found, and the establishment in connec- 
tion therewith of depositaries in different parts of the city 
where can be collected cast-off garments and donated fabrics 
suitable for the manufacture of clothing, and other articles of 
daily use ; and where also need} r mothers, without work, may 
find employment, at even better wages than could be obtained 
from dealers, in making and repairing such necessary wearing 
apparel as might be dispensed to those in need. In this man- 
ner the scraps and remnants of unused fabrics and aban- 
doned clothing, not unfrequently sold by pilfering servants 
to the rag-gatherer, at the alley-gate, might be utilized in 

1 The St. John's Guild, of New York, has established, in connection 
■with its other charitable operations, a sewing department, in which 
women and girls are taught to do " shop work," and which gives them 
such employment as it can during the winter. " Lady volunteers are 
brought into immediate association with the poor and hungry sisters 
who are unable to earn a livelihood, and those who are blessed with cult- 
ure, intelligence, and influence give the helping hand which puts the less 
fortunate in the way of comfort and independence." (Report of 1880.) 



44 THE MORTALITY OF YOUNG CHILDREN. 

securing the privilege of the health excursions to many little 
children to whom it would otherwise be inaccessible. 

It may not be any part of the duty of this institution to 
clothe naked and feed hungry children, but clothing, cleanli- 
ness, and food 1 are the essential adjuncts of a health excur- 
sion, and very many will be excluded unless some plan is de- 
vised by which assistance in these particulars can be rendered. 
If not incumbent upon the management, it will be none the 
less the part of wisdom to secure through auxiliary organiza- 
tions the cooperation of the benevolent in promoting the 
health interest of the destitute class. In almsgiving, as in 
matters pertaining to health, the general public needs instruc- 
tion. System and organization in such activities are far more 
effective and economical than individual effort. Thoughtless 
and indiscriminate almsgiving is a prevailing and reprehensi- 
ble practice. It encourages vice and idleness, degrades hon- 
est poverty, and invites the infliction of cruelties upon defence- 
less children. In every populous city children are driven, 
hungry and half naked, by wicked and debauched parents, to 
walk the streets in sunshine and in storm, and beg with out- 
stretched hands and lying lips of every passer-by a penny's 
worth of bounty ; and woe betide the thriftless beggar-child 
who, having through many weary hours, in tutored cadences, 
sung and re-sung the Miserere of the sick and starving little 
ones at home, returns to the wretched lodging with an empty 
pocket. The aggregate amount of money thus contributed 
annually, and worse than wasted, can never be ascertained, 
but in all probability it far exceeds the sum which could be 
diverted, even if the custom was abandoned, to proper and 
charitable objects, for there are very many persons, who will 
dismiss a beggar from their presence, with a liberal dole be- 
fore the story of his suffering is half completed, who would 
higgle half an hour rather than give a half dime to any benev- 

1 On each excursion of St. John's Guild " every woman and child re- 
ceived an abundance of substantial and well-cooked food, consisting of 
fresh meat, vegetables, bread, butter, milk and (when recommended by the 
doctor) tea." 



THE MORTALITY OF YOUNG CHILDREN. 45 

olent purpose. No argument will convince such people of 
the indubitable fact that mendicancy will continue and in- 
crease so long as it commands a premium and can subsist on 
the bounties of the thoughtless. If half the money and ma- 
terial wasted by injudicious individual giving could be dis- 
bursed through a well-directed, systematic, and organized 
agency, destitution, suffering, and disease would be greatly 
lessened, and the condition of many paupers be so much im- 
proved that they would become not only self-supporting, but 
contributors to the wealth and power of the state. It has been 
truly said that " a large and healthy population is the life and 
strength of a nation, and the source of its success in science, 
art, agriculture, and commerce." The laboring classes are the 
instruments for the creation of wealth, and all the comforts 
and luxuries which it brings. Surely, then, it is the duty as 
well as the interest of every one to save the little children of 
this class from the preventable diseases which cost so many 
lives and such an immense loss of treasure. The densely in- 
habited courts and alleys of every populous city are so many 
gold mines, which properly and intelligently worked would 
yield more wealth than the fabled Eldorado. There is no 
lack of good intention or willing hands, but for want of sys- 
tematic, concerted, and harmonious effort the sum total of 
good accomplished is far less than it should be. 

There is also a class of over-zealous humanitarians whose 
good intentions are without a balance wheel and who are as 
profligate in disbursement as they are assiduous in the solicita- 
tion of alms. Upon a few petted and pampered favorites 
means and effort are lavishly bestowed, and luxuries are sup- 
plied, of the value and use of which the recipients know no 
more than a brute does of a holy-day or sacerdotal ceremony ; 
and, fortunately, it is so in many cases, for the waste of such 
largess is less detrimental than the uses to which they might 
be applied. It is the repetition of the old story of casting 
" pearls before swine." Health, nutritious food, decent protec- 
tion of the person, and proper shelter are what poor children 
most need. 



46 TEE MORTALITY OF YOUNG CHILDREN. 

Among the affluent and society people there are very many 
whose good resolves, benevolent impulses, generous intentions, 
and liberal proposals are frittered away in harmless dissen- 
sions, weary formalities, individual rivalries, sectarian and de- 
nominational prejudices, or some other more frivolous and 
equally unfortunate exhibition of the weakness of human 
nature, or are permitted to languish and die out because of 
lack of force, indirectness of purpose, and absence of united 
effort. If the laity could be educated to a full realization of 
the facts that nearly one half of all children born die under 
five years of age, and that the larger part of this mortality 
results from preventable diseases, the better elements of nat- 
ure, and the instinctive love of mankind for children, would 
dominate personal bickering and factious discord, and unite 
the mass of the better-to-do class in a common struggle to 
alleviate the sufferings and prolong the lives of little children. 
Who with these facts before him is exempt from responsibil- 
ity, or would refuse to contribute his mite to such an activ- 
ity ? The medical profession has, especially during the pres- 
ent century, labored to combat the ravages of the maladies of 
early life, and has succeeded, through diligent research, skilled 
observation, discovery of new remedies, and more scientific 
treatment, in reducing the ratio of mortality under five years 
of age. Much more remains to be done by curative, but far 
more may be accomplished by preventive measures. In this, 
as in the study of the nature and treatment of disease, the 
science of medicine must assume the leadership. The art of 
preserving health is not, however, the exclusive prerogative 
of physicians ; unsupported by public opinion and unaided by 
the civil authorities the profession can do little more than 
point out the evils of bad hygiene and suggest the methods of 
correction ; and, perhaps, here and there impress a discreet 
mother with the folly or wrong of a blind adherence to the 
customs of a grandmother, or to the dicta of a venerable fossil 
who boasts that she has reared a dozen or more sons by stuff- 
ing them with the masticated pulp from her own morsel. 
The average man will listen to the doctor only when he fears 



THE MORTALITY OF YOUNG CHILDREN. 47 

the devil awaits at his door to conduct his craven spirit to 
eternal perdition, and so soon as assured that the evil demon 
awaits in vain or has departed, his gratitude, generosity, and 
sometimes his sense of justice, ekes out in mere words of 
slaver. But then, it would be manifest injustice to charge all 
this extraordinary mortality to the derelictions of the laity. 
There are dunderheads in the medical as well as shysters in 
the legal profession ; and no other avocation in which man can 
engage affords such opportunities to conceal error, practice 
fraud, or misrepresent the truth. In the seclusion of the sick 
chamber and privacy of the consultation room, audacious and 
culpable ignorance oftentimes hides its venality and malprac- 
tice in the verbiage of a language unknown to ordinary peo- 
ple and unintelligible to the learned ; and sickness and sorrow 
are laden with the requisitions of misapplied and pernicious 
agencies, administered under the garb of a special skill in the 
treatment of the particular complaint, it matters not what 
that may be. Little children, whose remonstrances can be 
expressed only in the language of suffering and disease, are 
thus frequently victimized to the credulity of unsuspecting 
parents. 

The summer sanitarium, with its liberal endowment and 
independent authority, possesses facilities and advantages 
never before equaled in this country for the education of the 
masses in the art of preserving health. It is charged with 
the special duty of alleviating the sufferings and prolonging 
the lives of little children. In this special department of 
sanitary science it must assume the leadership, and the good 
and bad results of its operations should be made known 
throughout the civilized world, that the good may be culled 
from the bad, and that other less fortunate communities m&y 
be educated by its example in the methods of saving life by 
preventing disease. To fully discharge this duty, as impe- 
rious as it is important, it must invoke the assistance and good 
will of all classes, high and low, rich and poor, learned and 
unlearned. To confine its operations within the limited 
sphere of simply furnishing, and providing conveyance to, a 



48 THE MORTALITY OF YOUNG CHILDREN. 

country resort and play-ground, to which children may go at 
pleasure during the heated months of the summer, and to lose 
sight of the higher aim as an educator with unrivalled re- 
sources for the practical instruction of parent and the general 
public in personal and domestic hygiene and alimentation of 
young children, would be a sad commentary on the philan- 
thropy of its founder. 

It must necessarily seek through good report to inculcate 
its lessons of wisdom, rather than enforce them through the 
majesty of law. It is not probable that in a country where 
the sovereignty of the individual citizen is the unit of power 
that the salutary influence of law will ever be available to 
force acceptance upon those for whose benefit charitable insti- 
tutions are established, but very much may be accomplished 
in matters pertaining to health by the enactment and impar- 
tial execution of health ordinances. The State of Maryland 
will never sanction, nor will the municipality of Baltimore 
ever enact a law to compel any class of its citizens to accept 
the gratuitous privileges of the Thomas Wilson Sanitarium, 
but the time is not far distant when public opinion will de- 
mand legislation in the interest of health far in advance of 
any that has heretofore been tolerated. The cupidity and 
self-interest of every citizen, if there were no higher incen- 
tives, will insist upon additional and more exacting legislation 
in sanitary matters. When the representatives of the whole 
people of the United States in Congress assembled can enact 
a law authorizing and directing policemen to enter any dwell- 
ing in the District of Columbia on suspicion that water is 
being wasted, and of his own volition cut off the supply, and 
arrest and drag to trial the head of the family, the time ought 
not to be far distant when the same authority will declare 
domiciliary and personal filth, bad air, over-crowding, spoiled 
food, malaria and infection nuisances detrimental to health 
and decency ; and neglect, bad nursing of and cruelties to 
little children, and bad cooking misdemeanors punishable by 
fine or imprisonment. Such authority may be irresponsible, 
but nevertheless a system of house-to-house inspection under 



THE MORTALITY OF YOUNG CHILDREN. 49 

the direction and management of a properly organized health 
department must sooner or later become a part of the munici- 
pal code of every populous city. It will be dictated by a 
sense of self-security, and protection from the preventable 
causes of disease, and by considerations of gain and economy. 
As an aid to the success of the sanitarium a municipal health 
department will be an important if not a necessary adjunct. 

THE DOMICILIARY OR HOSPITAL DEPARTMENT. 

To this department will be admitted those children who 
will need constant and continuous care, nursing, and feeding, 
for a shorter or longer time, under the immediate supervision 
and direction of skilled management. The determination of 
the earlier age of admission must therefore be made before 
the construction of the necessary buildings, and involves many 
important considerations. 

The reception of nurslings from the date of birth will con- 
cede the right of the mothers to accompany their infants, and 
incur the additional expense of providing proper accommoda- 
tions, and the maintenance of a number of mothers. The 
capacity of the institution as a place of temporary domicile 
must be limited by some definite relation of the size and plan 
of the buildings to the number of patients and area of terri- 
tory, otherwise it might cease to be a sanitarium supplying 
fresh and invigorating air to its occupants. The admission 
and support of such mothers would diminish the number of 
children at any particular period at least equally with the 
number of the women, nevertheless the educational ad- 
vantages which such women might derive by even a single 
summer's sojourn in such an institution may more than com- 
pensate in its remoter results for the diminution in the num- 
ber of its beneficiaries. 

It is a lamentable fact that much disease and suffering 
among infants and a very large percentage of the mortality is 
directly traceable to the ignorance and mismanagement of 
mothers. Most young mothers are entirely ignorant of their 
duties, and of the dangers which beset infantile life. They 



50 THE MORTALITY OF YOUNG CHILDREN. 

eagerly accept any information volunteered by a nurse, or the 
officious suggestions of a maiden aunt or of the neighbor, " so 
good in sickness," and learn when it is too late that the skill 
and experience of a well-educated physician is far more valu- 
able than the advice of any casual observer, however intelli- 
gent. 

The time has come when many otherwise well-meaning 
persons, who assume to direct the medical management of 
sick children, should recognize the responsibility incurred by 
attempting to do that which only those skilled in the science 
of medicine can hope to do successfully. No one will submit 
the delicate machinery of a watch to the rough usage of a 
blacksmith, yet the disorders of infancy, oftentimes trivial in 
the beginning, are frequently made worse by dosing with un- 
suitable medicaments, because a neighbor's child happened to 
get well in spite of similar bad treatment. It is only the ed- 
ucated eye, touch, and judgment which can properly detect 
and value s} T mptoms and their slight differences. Amateur 
doctoring may occasionally (Annie M. Hale, M. D.) do well, 
but it is an unsafe dependence. 

The teaching of mothers how best to nurse and to feed 
those needing artificial alimentation, either because of insuffi- 
cient supply or inferior quality of breast milk, or who may 
have reached the age when additional food is necessary, is an 
important and indispensable requirement of any systematic 
effort to prevent sickness and to lessen the mortality of early 
life. The only efficient method of accomplishing this, espe- 
cially among the poor and ignorant classes, is practically to in- 
struct them by making them, under the immediate observa- 
tion of competent superintendents, perform every necessary 
act in selecting, properly preparing, and preserving suitable 
articles of diet, and in the time, quantity, and manner of feed- 
ing. Verbal directions are too often forgotten, and when 
written the language is frequently misunderstood. Many in- 
fants are sacrificed through inattention to or omission of some 
apparently trivial matter, not because of neglect or unwilling- 
ness to do, but because of incapacity, ignorance, or want of 



THE MORTALITY OF YOUNG CHILDREN. 51 

method. Milk, which is so universally employed as an article 
of diet, is frequently supplied in sufficient quantity and of 
good quality, but is spoiled either by some improper mode of 
preservation or preparation, and thus is not only rendered un- 
fit as an aliment, but the cause of serious and often fatal ill- 
ness. Even when not otherwise injured it may be fed from 
an unclean vessel, or sucked through a dirty mouth-piece. 

The education of such mothers is not free from difficulty, 
and many will, after their discharge from the institution, re- 
lapse into their former habits ; but some, thus thoroughly 
trained, will become instructors, each in her respective circle 
of acquaintance. The proverbial fondness of women for im- 
parting to others what they think they know of the manage- 
ment of children may be thus utilized as a channel through 
which useful information may be disseminated, many errors 
corrected, much sickness prevented, and many lives saved. 
To a limited extent at least, dependent upon the capacity 
and intelligence of the women, each will acquire by observa- 
tion and association some knowledge of the causes of disease 
and how to avoid them, of its course, and of favorable and 
unfavorable symptoms ; but, perhaps more important than 
all things else, she will be taught to know that the summer 
infantile ailments are preventable and curable. The educa- 
tion of mothers to this single conviction, coupled as it must 
necessarily be with the realization of personal responsibility 
for the welfare of her nursling, will effect vast improvement 
in infant hygiene, and strike at the root of parental indiffer- 
ence and neglect. 

If, however, the advantages of the sanitarium are accorded 
to infants whose mothers (poor and needy though they be) 
are animated by the tender sensibilities and affectionate care 
known only to a mother, and who supply the natural and nec- 
essary aliment to the child, can it be denied to foundlings and 
other nurslings who may have been deprived, through the ac- 
cidents of .labor and by disease, of maternal care and suste- 
nance? The admission of the abandoned and motherless 
classes of nurslings would impose additional cares, incur grave 



52 THE MORTALITY OF YOUNG CHILDREN. 

responsibilities, and probably augment the current expendi- 
tures ; but mere considerations of policy, which do not pre- 
sent insurmountable obstacles, should not determine their ex- 
clusion. It is true that most large cities are provided with 
hospitals and asylums for the reception and care of foundlings, 
but there always will remain a number of these, and very 
many motherless infants who find refuge among kindred, and 
in poor and needy families, who will not relinquish to any in- 
stitution permanent possession of their wards, to whom the 
privileges of a summer's retreat from the heated air of the 
city and the baneful influences of squalid habitations will 
prove a boon of inestimable value. 

During the first or nursing period the probability of sick- 
ness and mortality are disproportionately larger than during 
the subsequent periods of childhood. The greatest mortality 
occurs during the first month, 1 and though it gradually lessens 
during each succeeding month, it aggregates at the termina- 
tion of the first year one fourth of all the births. 

The causes which conduce to this mortality include the un- 
avoidable diseases inherited from one or both parents, the 
congenital diseases and defects of formation, and the numer- 
ous preventable disorders specially incident to infantile life. 
Many of the congenital diseases and malformations are incur- 
able and, perhaps fortunately, terminate life during the earlier 
months; but some of the transmitted vices of constitution are 
remediable. The syphilitic infection submits, as a rule, to 
early medication and suitable regimen; and the scrofulous 
and phthisical predispositions, if not entirely eradicated, are 



1 Quetelet says: "There die during the first month after birth, four 
times as many children as during the second month after birth, and almost 
as many as during the entirety of the two years that follow the first year, 
although even then the mortality is high. The tables of mortality prove, 
in fact, that one tenth of children born die before the first month has been 
completed." 

In the city of Baltimore there died during the years 1875-78, 8,549 
children under one year of age; 3,563 between one and two years of age; 
and 1,868 between two and five years of age. 



THE MORTALITY OF YOUNG CHILDREN. 53 

frequently so modified and improved by timely and appropri- 
ate hygienic and dietary regulations as to insure comparative 
good health throughout a long and useful life. But it is the 
preventable causes of disease which demand special attention 
in an institution of this character. And, notwithstanding the 
marvelous advances in the treatment and prevention of the 
diseases of earl} 7 life during the past decade, the opportunities 
for further improvement are limited only by the constantly 
increasing population of the habitable world. The perfection 
of life and happiness cannot be attained while such a large 
proportion of children die under five years of age from avoid- 
able diseases. 

The post-natal causes of the morbility and mortality of the 
nursing age find their origin in the condition of the body as 
well as in the circumstances of life. With the completion of 
birth, important changes take place in the organism. The 
function of respiration begins, and the lungs, previously only 
passive and non-essential adjuncts of intrauterine life, are sud- 
denty and violently transformed into organs, without which 
an independent existence cannot be sustained. The circu- 
latory system becomes self-sustaining, receiving oxygen and 
eliminating carbonic acid through the lungs ; the alimentary 
tract, which previous to birth was only the receptacle of de- 
bris, now assumes the important functions of digestion and 
depuration ; the skin, which had been bathed in the high 
temperature of an innocuous fluid and protected by the more 
or less thick coating of a fatt} 7 secretion, is suddenly exposed 
to the detrimental influences of a medium of greatly lowered 
temperature, and subjected to the cruel formalities of super- 
stition, ignorance, and destitution ; and the brain, which at 
birth is a semi-diffluent mass of material, begins a rapid 
growth, with increased blood supply and organization of nerve 
and intellectual organs. To these must be added the delicacy 
and softness of the anatomical structures, and the helplessness 
common to all and the feeble vitality of many. 

These developmental changes are the physiological attri- 
butes of infantile individuality ; nevertheless, the new duties 
thus imposed upon the organs involved entail a tendency to 



54 



THE MORTALITY OF YOUNG CHILDREN. 



special diseases, which is vastly increased by the improprieties 
of infant hygiene and the circumstances of life. The death- 
rate is higher among the first bora than among subsequent 
births; higher in cities, more especially in the densely popu- 
lated parts, than in the country ; higher among the needy 
poor than among the affluent and well-to-do ; higher in local- 
ities where those employed in manufacturing industries reside, 
than in agricultural regions ; higher during the prevalence of 
epidemics than during seasons exempt from such deleterious 
influences ; and higher among the illegitimate than among 
those born in wedlock. All these contingencies of life are 
more or less favorably impressed by the life, dwelling, habits, 
and education of the family. This mortality is not, however, 
confined to the children of the poor, or of those living in nar- 
row and foul alleys, or of the dwellers in the ill-ventilated and 
stinking tenements of populous cities, nor to the improperly 
fed, to the early weaned, the harshly treated, or the impru- 
dently exposed, for all these causes are, presumably, of as fre- 
quent and constant occurrence during the winter as during 
the summer months ; yet it is during June, July, August, and 
September that the greatest mortality annually occurs. It is 
during these months that the highest mean monthly tempera- 
ture prevails. This general relation of mortality to a high 
average temperature is exhibited by the appended tabulated 
statements, 1 and is no less true of the city of Baltimore than 

1 TABLE I. 

[Prevailing direction of winds in summer months, S., S. E., S. W. In 
report of deaths under one year of age, still-born not included.] 













Temper 


ATCEE. 










Highest and Lowest. 


Mean Monthly. 




1875 


1876 


1877 


1878 


1875 


1876 


1877 


1878 




52-1 
59- 3 
63-19 
74-23 
88-42 
97-54 
93-61 
88-58 
92-43 
77-34 
65-16 
67-12 


71-17 
65-12 
69-12 
75-SO 
88-34 
95-51 
99-59 
90-55 
8S-45 
77-30 
76-25 
56- 1 


54- 1 
63-18 
65- 9 
80-32 
92-41 
95-55 
93-64 
94-63 
83-48 
80-41 
6S-25 
67-22 


57- 6 
63-20 
72-21 
79-42 
85-43 
92-51 
93-65 
92-59 
87-47 
80-35 
61-33 j 

61-15 ; 


30.1 
29.3 
39.5 
49.4 
64.1 
73.7 
78.0 
73.4 
65.9 
55.5 
42.9 
33.3 


41.5 

37. S 
39.8 
52.1 
61.2 
75.9 
80.4 
75.9 
65.6 
52.4 
47.1 
28.7 


32.1 
40.5 
41.4 

53.6 
62.7 
73.7 
78.7 
77.6 
67.9 
59.7 
48.4 
43.5 


35.7 


February 

Mar h 


47.6 
49.3 




53. 7 


Mav 


63.5 




70.1 


Julv 


80.8 




76.0 




69.3 




58.7 




47.3 


December 


35.4 



THE MORTALITY OF YOUNG CHILDREN. 



55 



of other large manufacturing cities. It is less in sparsely 
populated localities, less still in elevated regions, and least 
when to these conditions is added aridity. Then to the bane- 
ful influences of bad air, improprieties of diet, injudicious 
feeding, malnutrition, elevated temperature, personal neglect, 
and destitution must be added the conditions of moist atmos- 
phere, lowness of situation, and the congregation of a number 
of individuals within a limited area to complete the catalogue 
of causes and fill the measure of endemic requirements. 



METEOROLOGICAL INFLUENCES. 

The fact that very many young children die annually of 
the summer complaints 1 who are free from the detrimental 

Table I. Continued. 





Deaths. 




1875. 


1876. 


1877. 


1878. 






to 


OQ 




to 


m 




M 


03 




g 


<a 


































e 






<u 






a 


a 
w o 






<u 


C ■£ 


& c 


o 


rt£ 


c t 




C S 


C > 


O 


C !S 


c£: 




»> 




ss 


n £ 


SH 


ss 




SH 


2fc< 


U £ 


SH 


Sfe 






1-2 








m 05 








-a 3 


4) 5 


£* 


January. . . 


133 


39 


78 


116 


74 


35 


121 


85 


41 


104 


5S 


29 


February. .. 


153 


66 


70 


131 


62 


45 


122 


112 


35 


120 


44 


32 


March 


141 


54 


54 


152 


99 


45 


144 


155 


65 


151 


63 


41 


April 


113 


42 


38 


101 


56 


41 


135 


109 


42 


103 


44 


32 


May 


119 


29 


63 


105 


63 


28 


121 


88 


44 


161 


43 


38 


June 


236 


43 


36 


549 


88 


20 


382 


176 


43 


270 


58 


37 


July 


489 


66 


49 


418 


105 


20 


423 


140 


34 


257 


53 


34 


August 


259 


91 


25 


261 


119 


31 


248 


If 3 


35 


203 


65 


35 


September.. 


174 


90 


28 


1,4 


70 


34 


167 


109 


44 


125 


67 


34 


October. . .. 


165 


71 


22 


104 


49 


22 


98 


69 


57 


117 


42 


33 


November.. 


101 


46 


25 


89 


45 


25 


96 


63 


35 


116 


34 


46 


December. . 


133 


68 


30 


137 


95 


52 


125 


80 


43 


107 


33 


53 


Total 


2,216 


705 


508 


2,317 


925 


398 


2,182 


1,329 


518 


1,834 


604 


444 



1 " To determine the precise extent of their prevalence in any commu- 
nity is impossible, so inaccurately are the diseases of infancy and child- 
hood everywhere registered. Cases of fatal diarrhoeal diseases are re- 
corded under a great variety of designations, among which the following 
may be enumerated, as being the least equivocal: diarrhoea, cholera in- 
fantum, cholera morbus, enteritis, gastritis, gastro-enteritis, entero-colitis, 
inflammation of the bowels, dysentery, etc." (Curtis, Hygiene and Public 
Health, vol. ii., p. 281.) 



56 THE MORTALITY OF YOUNG CHILDREN. 

influences of foul air, privation, uncleanliness, over-crowding, 
and improper alimentation, points to some general agency, 
probably atmospheric, which affects alike all classes and con- 
ditions of life. When to this is added the further fact that 
these diarrhoeal diseases are almost exclusively confined to 
the heated months of the year, and are more prevalent in low 
and damp localities and during seasons of excessive rainfall, 
the conclusion seems manifest that continuous high tempera- 
ture and a humid atmosphere are essential elements of causa- 
tion ; yet that these two climatic elements are not the only 
necessary considerations is equally evident from the fact that 
these disorders are much less frequent in the Gulf cities and 
those on the Pacific coast, where the temperature is more 
uniform during the entire year, than in the cities of the Mid- 
dle and Northern States, which are subjected to very wide 
excursions of temperature between the extremes of heat and 
cold. Professor N. S. Davis, 1 of Chicago, who has studied the 
relation of bowel complaints, both in children and adults, to 
temperature and geographical region submits the following 
conclusions : — 

(1.) They are far more destructive to infants than to 
adults. 

(2.) They prevail almost exclusively during the warmest 
months of the year. 

(3.) They are most prevalent in the region of this country 
north of the north line of the Gulf States, and east of the 
Rocky Mountains. 

He asserts two additional facts, not previously recognized, 
which are of great importance : First, that these diseases 
occur in groups when the cases rapidly multiply during suc- 
cessive days for a week or fortnight, followed by an interval 
during which few or no cases occur ; and, secondty, that these 
groups correspond with the waves of continuous high temper- 
ature during day and night, which spread, at shorter or longer 
intervals during the summer months, over the northern cli- 
matic belt of this country, lasting from three to fourteen 

1 Trans. Amer. Med. Ass., vol. xxx., 1879, p. 145. 



THE MORTALITY OF YOUNG CHILDREN. 57 

days, and varying in intensity at different times and in differ- 
ent years. The first of these tropical waves usually occurs 
during the latter half of June, two or more occur in July, and 
one or two in August. 

To ascertain, with probable accuracy, the time of occur- 
rence and duration of these periods of continuous high tem- 
perature at different localities in the climatic belt of the 
country in which they annually recur, together with the ad- 
ditional information set forth, the following inquiries were 
addressed to General Albert J. Myer, Chief Signal Officer of 
the Army : — 

(1.) The date of beginning and duration of the periods of 
continuous high temperature for the cities of Washington, 
Baltimore, New York, and Chicago, for the years 1876, 1877, 
1878, and 1879 ; and the mean daily temperature of each 
period. No period of less than three days to be considered. 

(2.) Amount of rainfall at same places during each period 
or at their termination. 

(3.) Relative humidity of the air at each place during each 
period. 

The accompanying tabulated statement (Table II.), cour- 
teously supplied by that distinguished officer, fully answers 
these inquiries. 1 

The cities named were selected without any previous exam- 
ination of the data to be supplied, or knowledge of the 
information to be derived therefrom. If a lower standard 
than that of the normal for July at each locality with the 
addition of ten degrees had been adopted in the preparation 
of the statement, the periods of continuous high temperature 
would have been more numerous and of longer duration than 

1 The writer takes pleasure in acknowledging the polite and valuable 
assistance, which Lieutenant Craig and Professor Abbe have, with the 
permission of General Myer, rendered him in his effort to study the rela- 
tion of the meteorological phenomena to the causation of infantile diar- 
rhoeas. He has been supplied, upon request, with data from the official 
records of the bureau which have enabled him to consummate the results 
set forth in these pages. 



58 



THE MORTALITY OF YOUNG CHILDREN. 



TABLE II. — Statement showing the Periods, in the Months of May, 
during which the Temperature of the Air rose Ten Degrees or more 
City, N. Y., and Washington, D. C. ; also, showing the Mean Tem- 
duriny the specified Periods. Compiled from the Records on fie at 



1. The normal for July, with ten degrees added, is as follows : 

2. The dash ( — ) in the columns for the rainfall indicates that the 



Baltimore, Md. 


Chicago, III. 




Temperature. 


£*; 






Temperature. 


•fi 










d| 


Rain. 








ft 2 


Rain. 


Dates. 






c 2 


Inches. 


Dates. 






c S 


Inches. 




Max. 


Mean 

Daily. 


£ 3 

~ — 






Max. 


Mean 
aily. 


ei 3 




1876. 










1876. 










June 24 


90° 


80.7° 


59.7 





June 24 


85° 


78° 


70.7 





25 


90 


81.7 


57 





25 


85 


79.2 


72.3 





26 


94 


84.2 


58.7 





26 


87 


80.5 


72.7 


.04 


27 


95 


85.2 


57.3 


— 


July 6 


90 


80.2 


77.3 





28 


93 


80.7 


66 


.59 


7 


93 


84.7 


66.3 





July 2 


94 


85.2 


68.7 





8 


93 


85.7 


61.3 





• * 3 


93 


84.7 


54.3 





9 


93 


83.7 


64.7 


.02 


4 


95 


80.7 


61.7 


.22 


Aurr. 22 


85 


77 


623 





5 


92 


82.7 


67.7 


.15 


23 


92 


83.2 


64.7 





6 


90 


81.2 


61 


.01 


24 


85 


79.2 


75.7 


.88 


8 


97 


88 


59.7 





1877. 










9 


99 


90.2 


533 


o 


July 7 


86 


77.7 


67 





10 


97 


88.2 


60.7 





8 


91 


80.2 


72.3 


.01 


11 


96 


84 


70.3 


.21 


9 


89 


78.5 


82.3 





12 


96 


82.7 


68.3 


.05 


26 


88 


SO 


72.7 


.02 


13 


95 


83.2 


68.7 


.25 


27 


86 


78.7 


72 


.01 


14 


91 


83.2 


65.3 


.90 


28 


84 


76 


87.7 


.54 


15 


91 


81.7 


63 


.01 


Aug. 26 


84 


74 


63 





16 


90 


81.2 


51.3 





27 


89 


77 


78.7 


.04 


17 


90 


82 


61.3 





28 


84 


74.2 


83.3 


.46 


18 


93 


83.7 


60 


.15 


1878. 










19 


92 


85.5 


67 





July 7 


85 


78.7 


72.7 





20 


97 


87.7 


64.3 


.19 


8 


86 


78.5 


76.7 


— 


1877. 










9 


87 


79 


73.7 


.11 


July 25 


92 


81.5 


59.3 


.01 


14 


87 


81 


77.3 





26 


92 


84.2 


62.3 





15 


88 


82.5 


71 





27 


93 


84 


72 


.50 


16 


97 


88.2 


61.7 





28 


92 


79.5 


76 


.02 


17 


95 


89.2 


61.3 





1878. 










18 


88 


75.7 


74 





July 4 


92 


81.5 


67 





; l 


89 


80.2 


55.7 


.01 


5 


92 


83.7 


61.3 





Aug. 1 


87 


78.5 


56 


.09 


6 


92 


83.7 


48.7 





2 


84 


77.2 


66.3 





7 


90 


81 


54.7 





3 


84 


77.7 


67 





8 


92.5 


81.2 


71.3 


.02 


4 


85 


78.5 


65.7 


.12 


9 


91 


82.2 


73 


.32 


5 


87 


77.7 


71 





10 


94.5 


84.7 


62 


.26 


1879. 










11 


91 


84.2 


60 





June 23 


86 


78.7 


58.7 





17 


91 


82.2 


73.7 





24 


87 


79.7 


61.7 





18 


98 


88 


62.3 





25 


85 


79.7 


59.7 






THE MORTALITY OF YOUNG CHILDREN. 



59 



June, July, and August, of the Years 1876, 1877, 1878, and 1879, 
above the July Normal at Baltimore, Md., Chicago, III, New York 
perature, Mean Relative Humidity, and Total Rainfall for each Day 
the Office of the Chief Signal Officer, U. S. A., Washington, D. C. 



Baltimore, 89.6°; Chicago, 84.4° ; New York, 84.9° ; Washington, 89.3°. 
amount of precipitation collected in the run gauge was too small to measure. 



New York City, N. Y. 




"Washington, D. 


C 






Temperature. 


r^iA 






Temperature. 


fi 










I:-g 


Rain. 








fi2 


Rain. 


Dates. 






d 3 


Inches. 


Dates. 






c 5 


Inches. 




Max. 


Mean 
Daily. 


e 3 
a) i— t 






Max. 


Mean 
Daily. 


eS 3 

<B — 1 




1876. 










1876. 










June 24 


88° 


77.7° 


69 





June 25 


91° 


80.6° 


58 





25 


87 


78.2 


53.7 





26 


93.5 


83.7 


61 





26 


92 


80.5 


61 





27 


96 


84.2 


58 


.02 


27 


90 


79.5 


67.3 


.03 


28 


95 


80.2 


68.3 


.84 


28 


89 


79.5 


62.7 





29 


91.5 


80.7 


72.7 


.03 


29 


85 


77 


56.7 





July 1 


91 


82.4 


69 


— 


30 


87 


78.7 


58.3 





2 


94.5 


86.1 


64.3 





July 2 


94 


85 


61 





3 


91 


86.2 


53.3 


— 


3 


88 


80 


58.3 





4 


96 


81.5 


63.3 


.31 


4 


90 


81.2 


57.7 





5 


94 


84 


66.3 


.01 


5 


86 


80.7 


64 





7 


92 


83 1 


65 





6 


85 


77.5 


50.7 





8 


95 


86.7 


63.7 





7 


88 


77 


51.3 





9 


97 


87.7 


60.7 





8 


98 


83 


65.7 





10 


97 


83.7 


79.7 


.10 


9 


99 


84.5 


61.3 





11 


98.5 


87.1 


59.3 


— 


11 


90 


80.2 


68.3 


1.97 


12 


98 


85.7 


61.3 


— 


12 


91 


80.5 


75.3 





13 


93 


82 


70.7 


.30 


13 


97 


84.5 


54.3 





14 


91 


81 


74.3 


.03 


14 


89 


79.2 


68.7 


.01 


17 


91 


82.7 


64 





• 15 


93 


81.7 


53.7 





18 


93 


85 


59 





16 


87 


77. 


54 





19 


95 


86.7 


633 


— 


18 


88 


80.5 


69.7 


.38 


20 


98.5 


87.2 


66 





19 


95 


81.7 


64.7 


.05 


Aug. 15 


91.5 


80.4 


73.7 





20 


93 


83 


71.3 


.03 


16 


93 


82.2 


66 





21 


88 


79 7 


50 


.10 


17 


90.5 


80.2 


73.3 





Aug. 6 


87 


77.5 


71.3 





1877. 










7 


90 


79.5 


74 


.60 


July 25 


90.5 


81.2 


65.7 





8 


89 


80.7 


52.3 





26 


96 


87 


62.3 





9 


86 


76.2 


58.3 





27 


98 


83.2 


70.7 


.39 


1877. 










28 


95 


79.7 


79.7 


1.30 


June 1 


85 


75.7 


45.3 





Aug. 27 


91 


80 


66.3 





2 


88 


76 


53.3 





28 


92.5 


81.7 


71.7 





3 


85 


73.5 


61 


.18 


29 


94 


83.2 


62.3 





July 24 


87 


79.5 


58.7 





30 


89.5 


80.5 


64.3 





25 


90 


80.5 


59.7 





31 


91.5 


80.5 


63 





26 


93 


84.5 


50.7 





1878. 










Aug. 26 


85 


79.5 


73.3 





July 2 


89.5 


79 


75.3 


— 


27 


90 


78.2 


57 





3 


91 


81.7 


69.7 





28 


88 


79 


63 





4 


94 


83 


67 






60 



THE MORTALITY OF YOUNG CHILDREN. 



TABLE II., Periods of High 



Baltimore, M<3., Continued. 



Chicago, III., Continued. 





Temperature. 


5± 






Temperature. 


— >> 










P2 


Rain. 








n: 2 


Rain. 


Dates. 






c 2 


Inches. 


Dates. 








Inches. 




Max. 


Mean 
Daily. 


| 3 






Max. 


Mean 
Daily. 


a; — i 




1878. 










1879. 










Julv 19 


95.5 


84.7° 


62.7 


.17 


Julv 13 


86° 


82.2° 


T4-7 





20 


92 


84.7 


63.7 





14 


91 


86 2 


58.7 





21 


95 


85 


62.3 


.05 


15 


93 


8S7 


64 3 





1879. 










16 


90 


75 5 


56.3 





July 15 


94 


84 


55 


— 


Aug. 1 


88 


82 2 


48.3 





16 


99 


90 


49.3 





2 


91 


84.7 


53.7 





17 


91 


82.5 


39.7 





3 


85 


77.7 


72.3 


.01 


Aug. 2 


92 


83.2 


58.7 





20 


85 


77.7 


59.3 





3 


92 


82.7 


63.7 


— 


21 


88 


79.5 


62 





4 


90 


80.2 


72.3 


.26 


22 


87 


81.2 


55.7 





5 


90 


82.7 


68 















6 


90 


84.5 


57.3 
















THE MORTALITY OF YOUNG CHILDREN. 



61 



Temper at u re, Con tinued. 



New York City 


N. Y., 


Continued. 


Washington, 


D. C, Continued 






Temperature. 








Temperature. 


£>. 










A3 


Rain. 








RJ2 


Rain. 


Dates. 






a S 


Inches. 


Dates. 






s S 


Incces. 




Max. 


Mean 
Daily 








Max. 


Mean 
Daily. 


7 = 




1877. 










187S. 










Aug. 29 


89° 


77.2 = 


67 


.13 


July 5 


91.5° 


82° 


70 





1878. 










6 


93 


83.5 


58 





June 27 


87 


78.2 


62 





7 


91 


80.5 


52 





28 


88 


80 


57.3 





8 


96.5 


83.7 


66.3 





29 


86 


77.5 


62 





9 


93.5 


82.2 


71.7 


.21 


Julv 1 


86 


76 


69.3 





10 


96 


80.7 


73.3 


.10 


2 


87 


76.7 


72 





11 


93 


84 


65 


— 


3 


88 


77.5 


76 





12 


93.5 


80.7 


79.3 


.83 


4 


88 


76.5 


75.3 


— 


17 


94.5 


83.2 


73 





5 


92 


82. 


58 





18 


98 


89 


63.3 





6 


85 


77 


38.3 





19 


96.5 


83 


74.3 


1.10 


8 


88 


77 


73.7 


.13 


20 


91 


82.6 


743 





9 


88 


76.2 


83.3 


1.26 


21 


95.5 


84.2 


69.7 





10 


86 


77 


72.7 


.02 


31 


91 


80 


68.3 


— 


18 


93 


83 


74 


.41 


Aug. 1 


93 


81.5 


75.3 


.64 


19 


94 


84.7 


68.3 


.01 


2 


89.5 


80.6 


61.7 


— 


20 


87 


78 


59.3 





3 


92 


80.5 


63 





Aug. 2 


85 


74.2 


74.7 


1.46 


4 


92 


805 


69.7 





3 


88 


77.2 


62.3 





5 


90 


77.2 


77.7 


2.15 


4 


85 


75.5 


68.3 


.12 


1879. 










1879. 










May 31 


94 


82.2 


65.3 





May 31 


86 


76.2 


71 





June 1 


95 


82.5 


57.3 





June 1 


89 


79.7 


64.7 





2 


90 


77 


67 


.45 


2 


86 


75 


70.7 


.24 


26 


91.5 


80 


63.7 





July 14 


85 


76.7 


57.3 





27 


94.5 


83.2 


59.7 





15 


92 


82.2 


58 





28 


95 


82.2 


63 


.09 


16 


94 


78.7 


70.7 


.42 


July 2 


90 


79.5 


50.3 





27 


86 


77.2 


70 


.06 


3 


95.5 


83 


50.3 





28 


85 


76.5 


75 





4 


99 


84.7 


50.3 


.02 


29 


85 


77.7 


6S.3 


.01 


14 


91 


79.2 


55.7 





31 


89 


77.5 


54 





15 


98.5 


86.7 


52.3 





Aug. 1 


86 


76.5 


80.7 





16 


102 


88 7 


51.7 





2 


90 


80.5 


74.3 





17 


90 


80.7 


45 





3 


89 


79.5 


70.7 


— 


22 


93 


81.2 


59 















23 


93 


83.7 


53.7 


.02 












24 


91.5 


81.2 


64 


.02 












Aug. 1 


90 


79.2 


74.3 















5 


94 


81.7 


63 















3 


94 


84 


61.7 















4 


92 


80.5 


73.3 


.32 












5 


93 


83.2 


71.3 


— 



62 THE MORTALITY OF YOUNG CHILDREN. 

are shown in the tabulated arrangement, but they would have 
been less distinctive as exacerbations of temperature, and 
consequently less valuable in exhibiting the relation of such 
periods to the prevalence of the infantile intestinal diseases. If 
the July normal at each of the four localities had been adopted 
as the basis, a more uniform temperature would have been 
shown for the months named at each of the places selected, 
and very many days would have exhibited a daily mean and 
minimum too low to be regarded as a heat factor in causing 
bowel complaints. In fact it would have transferred the 
question from the study of the exacerbations of temperature 
as a causal element to the consideration of the duration of 
summer heat as the essential and important agency. 

The periods are of shorter duration in Chicago and New 
York, and occur quite as early as in Washington and Balti- 
more. The earliest stated began May 31, at New York, in 
1879, and the latest terminated at Washington, August 31, 
1877. The first usually begins during the latter half of June 
and either extends into July, or is succeeded, after a brief in- 
terval, by the second period, which most frequently begins dur- 
ing the first seven days of July. In 1876, a period began al- 
most simultaneously in the four cities in June. Two or more 
periods usually occur in July, and the average maximum and 
mean daily temperature of the periods are uniformly higher 
in July than in either of the other months. 

The normal for July is highest at Baltimore, but the high-' 
est average maximum temperature of the corresponding peri- 
ods is at Washington. (See Table XII.) 

A comparison of the four cities according to the average, 
for four years, of the maximum and mean daily temperature, 
and average relative humidity for the same period, will ar- 
range the cities as follows : — 



THE MORTALITY OF YOUNG CHILDREN. 63 

TABLE III. 



Chicago. 

87.4 
79.2 
67.3 



Average maximum temperature . . 
Average mean daily temperature . . 
Average percentage relative humidity 



Washing- 
ton. 


Balti- 
more. 


New 
York. 


93.9 


92.9 


88.5 


82.4 


83.2 


78.5 


63.8 


61.4 


63 



The atmosphere is never absolutely free from moisture. It 
is called dry when it contains less moisture than it might at 
the existing temperature ; saturated, when it can contain no 
more ; and damp, when its saturation is high relative to heat. 
The capacity of the air for moisture increases with the eleva- 
tion of its temperature, but the relative saturation of a given 
volume of air diminishes with the rise of its temperature. As 
a rule, the body loses more water through the skin and lungs 
when the air is dry than when it is damp. A warm and 
damp air diminishes the radiation of body heat, exhausts the 
muscular and nervous system, lessens the appetite, impedes 
digestion, and obstructs the respiration. So that an average 
mean daily temperature of 79.2°, with an average mean daily 
humidity of 67.3 per cent., as is shown to be the condition of 
the atmosphere of Chicago, is more oppressive than the higher 
average mean daily temperature of Baltimore, with a lesser 
average relative humidity of 61.4 per cent. Applying this 
rule to the four cities, they may be arranged according to the 
data for the heated periods of the four years named ; Balti- 
more possessing the most endurable temperature during those 
periods, and, successively, Washington, New York, and Chi- 
cago. Other things being equal, these meteorological obser- 
vations would indicate that the city of Baltimore, 1 or its vi- 

1 The temperature differences between Baltimore and Washington are 
hardly appreciable, but the relative excess of moisture in the air of Wash- 
ington favors the former city as the preferable locality of the two ; assum- 
ing that the hygrometric observations are sufficiently accurate to distin- 
guish between such slight differences of relative humidity. 



64 THE MORTALITY OF YOUNG CHILDREN. 

cinity, would be the most favorable of the four localities for 
the establishment of a summer sanitarium for the prevention 
and cure of the bowel complaints of young children. The 
meteorological data are, however, as yet insufficient to deter- 
mine the comparative healthfulness of different cities. En- 
demic influences, condition of soil, drainage, sewerage, local 
sanitary supervision, the character, pursuit, density, and pri- 
vation of the population, altitude, food suppl} 7 , and dwelling 
accommodations must enter largely into the consideration of 
the question. 

The temperature of the air diminishes, approximately, in 
the ratio of one degree to every three hundred feet of eleva- 
tion above the level of the sea ; the probability of more fre- 
quent and stronger currents of air increases with the altitude, 
and the relative humidity of the atmosphere at any given 
point ought to increase with ascent above the sea level. The 
movements of the air bear important relations to its tempera- 
ture and humidity. A calm, especially when the air is very 
warm, is detrimental to health, because the products of ani- 
mal and vegetable decomposition, and the exhalations from 
living bodies, are not diffused and dispersed. Ventilation is 
inadequate for the demands of health. Upon the direction of 
the currents depends, in a great measure, the heat and moist- 
ure of the atmosphere. By the movements of the air the ven- 
tilation of dwellings is promoted, and the air is dried. The 
influence of winds upon the production of disease is not very 
well understood. Cold, damp northerly and easterly winds 
provoke catarrhal and pulmonary diseases. Hot, dry south 
winds are enervating, and are supposed to exercise a peculiar 
evil influence upon very young children. The relation of the 
winds to the prevalence of special diseases varies with the 
season of the year. A current that would mitigate suffering 
during July and August might greatly augment it during the 
months of December and January, or even in the balmy 
months of spring. The relation of elevation to the tempera- 
ture, humidity, and movements of the air is an important 
consideration in directing the selection of a suitable location 



THE MORTALITY OF YOUNG CHILDREN. 65 

for a summer sanitarium for sick children. Diminished heat, 
agreeable relative humidity, freer ventilation, a purer and 
more salubrious air, are curative and preventive agencies es- 
sential to the clinical success of such an institution. These 
can be secured by the choice of some of the elevated plateaux 
in accessible proximity to the city of Baltimore. 

The data furnished by the Chief Signal Officer of the 
Army, previously summarized, lead also to very important 
and definite suggestions in regard to the time when an insti- 
tution of this character should annually begin active opera- 
tions. Preventive measures should commence before the time 
when the earliest period of continuous high temperature an- 
nually recurs, and continue sufficiently long to escape the 
probable time of the occurrence of the latest period. To 
cover the earliest date at which such high temperatures have 
occurred at Baltimore and Washington, the institution should 
be in readiness on or before the middle of June, and not close 
until the latter part of September or first of October. The 
latest period noted in the memoranda terminated on August 
31, 1877, at Washington, with a mean daily temperature of 
80.5°, and mean daily humidity of 64.3 per cent. Even 
though there might be few or no cases of disease after this 
date, the convalescent could not be safely returned to the city 
and to their lodgings before the temperature had fallen suffi- 
ciently to insure them against relapses. This is not likely to 
occur before the autumnal equinox. 

The first period, usually occurring during the latter half of 
June, is quickly followed by another of longer duration, with 
higher mean daily temperature and mean daily humidity, 
which envelops the entire middle and northern parts of the 
country east of the Rocky Mountains, beginning in some lo- 
calities as early as the first of July, in others usually not later 
than the fourth. 1 This exacerbation is followed by the greatest 

1 The average of the aggregate maximum temperatures of the fourth 
day of July for the cities of Baltimore, New York, and Washington, for 
the years 1876, 1878, and 1879, was 95.25°. 
5 



66 THE MORTALITY OF YOUNG CHILDREN. 

outbreak of bowel diseases among children. 1 Previous cases 
are made worse or suffer relapses, and a large number of new 
cases occur. Usually, two other but shorter periods follow 
this in the month of July. 

As a rule the largest monthly mortality of children under 
five years of age occurs annually in July. The following 
tabulated statements (Tables IV. and V.) show that the total 
mortality of children under five years, and the death-rate 
from cholera infantum, dysentery, and diarrhoea for a period 
of seven years in Philadelphia, 1862-68, (excepting 1863) 
and in New York, 1871-77, were, for each year in either 
city, higher in July than in June, August, or September. 
The same is true of Boston. 

If the mortality excess during July is due to the circum- 
stance that very many children, taken sick during the tropical 
period of June, die during the succeeding month, then it 
ought to follow that the number of deaths should be greater 
in August than in July, because there are two or more ex- 
acerbations of temperature, and very many more children are 
taken sick in July than in June. Undoubtedly, a large per- 
centage of the August mortality results from cases of sickness 
beginning in the preceding month. This fact, (as do the 
clinical and mortality statistics of July) indicates that the 
atmospheric condition peculiar to the summer months which 
seems to exert a specially detrimental influence upon children 
under five years of age is much more constant and intense in 
July than in either of the other months. What is this 
agency ? It is not the heat of a single day, as has been 
shown to be usual with the Fourth of July, nor the heat of 
several consecutive days, each followed by cool nights, for 

1 In this connection it is proper to invite attention to the greater prev- 
alence of disturbances of the alimentary tract in young children during the 
week following Christmas Day, the Fourth of July, and other gala clays, 
due manifestly to the improper indulgences of the appetite. Parents and 
kindhearted friends are very often responsible for cases of serious and, un- 
fortunately, sometimes fatal illness, which would not have occurred if they 
had adhered on such occasions to the simple and proper dietary to which 
the children had been accustomed. 



THE MORTALITY OF YOUNG CHILDREN. 



67 



CO CS -1 —I 



Cholera Infantum, 
Dysentery, Diarrhoea. 



Total. 



Mean Temperature. 



Cholera Infantum, 
Dysentery, Diarrhoea. 



Mean Temperature. 



Cholera Infantum, 
Dysentery, Diarrhoea. 



Total. 



Mean Temperature. 



Cholera Infantum, 
Dysentery, Diarrhoea. 



Mean Temperature. 



-Jt 


I*' 

CO 


30 


CO 

o 


Cholera Infantum, 
Dysentery, Diarrhoea. 


o 
"5? 


CO 
OS 

OS 


"co 
cs 
Id 


— 


to 

— 


CS 

GC 


Total. 


OS 

CO 

l 3 


o 


s 

CO 

o 


So 

o 

•o 


Mean Temperature. 





— ' CO 

o cs 


— 
~-1 


£ 


Cholera Infantum, 
Dysentery, Diarrhoea. 


o 
ST 
■5T 




"O "tO 

to ^ 


Qi 


co 

CO 

o 


Total. 


CO 

as 


OS ~1 
CO C» 

'to J-» 

t <3 


CS 

3 


-1 
to 

CO 

o 


Mean Temperature. 







s S 


03 

co 


CO 

CS 


Cholera Infantum, 
Dysentery, Diarrhoea. 


O 

p 


CO 
OS 
CO 


St -1 

CO O 


*CO 

s 
c 


"to 

o 


Total. 


CS ~T 

CO .30 
CO if*. 

o to 

o o 


X 

o 

CO 

— 

D 


eo 

CD 

o 


Mean Temperature. 




t-' CO 
O CS 
to i-i 


-4 


CO 


Mean Mortality for Seven Years from 
Cholera Infantum, Dysentery, and 
Diarrhoea. 


"to "co 

l-" to 

CJ» CO 


oo 

CO 


~1 

CO 


Mean Total Mortality for Seven Years. 



s 3 a i 

co cs i<i co I Mean Temperature for Seven Years. 



£ r t-i 

si i 

£ S3 §3 
111 

&§! 

life 

Is- s ** 
«»" S a 



p 


§ 


c/s o 
2 *S 




a 


cS" 5m 


& 




^ s 


4 J 

o 

3 






p 


OS 


5^ cSi 


H 
p 


a 


fe»k 




a 


a £ 




R.i 


-s ^ 


«* 


CS. 


""3 g 




» 


$ J* 


» 

a 


a a 

5s 


2> 


5s 


h-j 


fc> 


^ s- 






5- s 




5> 








g 

^ 






«s 

55 












« 


"^ 




as 


a <v* 



a* 5s 



68 



THE MORTALITY OF YOUNG CHILDREN. 



such periods of wide range of temperature between day and 
night frequently occur during the summer months, and even 
before and after, without any observable effect upon the 
health of infants. Continuous high temperature may be a 
constant factor, for the tables (IV. and V.) exhibit the 
correspondence of high monthly mortality with a high mean 
monthly temperature. Even the exceptional instance of the 
August mortality (1863) exceeding that in July corresponds 
with a higher mean monthly temperature for August of that 
year. And the same fact is shown by Table VI. 

TABLE V. — Showing the Mean Monthly and Annual Number of 
Deaths at New York, from Diarrhceal Diseases, of Children under 
Five Years, and at Different Ages under Five, for the Seven Years 
from 1871-77, and the Mean Monthly Temperature, Humidity, Rain- 
fall, and Atmospheric Pressure for the same Years. 

[Compiled from data published by Dr. John T. Nagle, Deputy Registrar of Records, in the " New 
York City Record," March, 1S78, toI. vi.] 







St 

S 

2 
o 


4 

cj 


< 


1 


o 

3 


"5 


2 

to 


1 

o 

CO 


o 
"8 

O 


o 

.a 
£ 

% 


a 

1 
o 
o 
P 




Diarrhceal Dis- 




























eases under 5 




























Years. 


41.4 


40.4 


50.6 


67.6 


86.9 


295.4 


1,383.4 


843.6 


117.0 


170.6 


63.1 


41.7 


3,434.7 


Ages, One and 




























under. 


519.4 


513.0 


568.0 


556.3 


559.9 


694.6 


1,714.3 


1,101.3 


744.6 


518.2 


137.1 


180.0 


8,409.7 


Between One 




























and Two. 


215.0201.1 


216.7 


215.1 


197.1 


308.0 


414.9 


376.1 


293.9 


207.7 


164.4 


184.0 


2,902.0 


Between Two 


























and Five. 


257.0 253.6 


279.4 


243.3 


244.0 


212.6 


230.1 


188.4 


186.0 


199.1 


223.3 


219.0 


2,760.8 


Meteorology. 




























Mean Tempera- 




























ture. 


29.6° 


30.7° 


36.0° 


16. r- 


59.9° 


70.4° 


75.4° 


73.6° 


64.9° 


54.2° 


41. 3 C 


31.8° 


51.2° 


Relative Hu- 




























midity. 


79 


76 


75 


61 


62 


66 


67 


63 


69 


69 


74 


78 


71 


Rainfall, in 




























inches. 


3.05 


2.65 


4.47 


3.88 


2.57 


3.17 


5 33 


5.41 


3.60 


3.96 


3.9C 


3.96 


44.35 


Atmospheric 




























Pressure. 


1.029 


.954 


.897 


.867 


.883 


.876 


.868 


.911 


.952 


.941 


.934 


.983 


29.923 



The following table, constructed by Dr. Curtis, shows the 
same relation of summer-heat to the diarrhoeal mortality in 
the city of Boston. 



THE MORTALITY OF YOUNG CHILDREN. 



69 



TABLE VI. 





Temperature at Cambridge Observatory. 


Diarrhoeal Diseases. 


Years. 












Mean Temp. Fahr. 


Mean Temp, during 


Death rate per One 


Percentage to all 




July and August. 


hottest Month. 


Thousand Living. 


Deaths. 


1867 


69.8° 


70.4° 


2.55 


9.70 


1868 


71.6 


73.6 


3.10 


13.20 


1869 


69.2 


70.8 


2.69 


11.44 


1870 


72.3 


77.9 


3.63 


14.92 


1871 


70.8 


70.9 




11.29 


1872 


71.9 


73.1 


4.10 


13.41 


1873 


69.4 


71.6 


3.29 


11.71 


1874 


68.6 


71.5 


2.70 


11.32 


1875 


70.8 


71.3 


3.36 


13.80 



If the years 1867, 1869 and 1874, during which the death- 
rate from diarrhoeal diseases varied from 2.55 to 2.70 per 1,000 
living, be compared with the other years, it will be seen that 
the larger number of deaths corresponds with the higher range 
of the temperature. Especially was this true with the year 
1872, when the rate reached 4.10 per 1,000 living. In Mas- 
sachusetts, the deaths attributed to cholera infantum alone 
amounted during ten years (1866-1875) to 18.6 per cent, of 
all deaths under five ; in 1872, the percentage reached 24. 
During the same year the mean temperature of July, at New 
York, was 79.57°, being 3.43° higher than that of the corre- 
sponding month during the previous ten years. During the 
summer quarter of that year the deaths under one year in the 
city of New York amounted to 59.33 per cent, of all deaths, 
and of the total mortality under one for the whole year, as 
much as 40.8 per cent, took place during the three summer 
months. Of all the deaths in the year 15.9 per cent, were 
due to diarrhoeal diseases. Of these deaths 3,542 occurred 
under one year of age, making over 10 per cent, of the entire 
mortality of the year. 1 From these facts Dr. Curtis concludes 
that excessive heat is the most destructive influence, and is 

1 These facts have been collated from the article on Infant Mortality by 
Dr. Thomas B. Curtis, of Boston, whose accuracy as a statistician is uni- 
versally recognized. 



70 THE MORTALITY OF YOUNG CHILDREN. 

more acutely felt by children under one year of age than by 
the older. The Registrar of Vital Statistics 1 of the city of 
New York, however, ascribes the great excess of mortality in 
July and August of 1872 to the " extremes of solar heat and 
an almost saturated condition of the atmosphere." 

Continuous high temperature may be a constant but cannot 
be the only meteorological influence, for the mean tempera- 
ture of June is greater than that of September, yet the mor- 
tality of the latter month is usually much larger than that of 
the former. The duration of summer heat and the lateness 
of the August exacerbation, are additional agencies which 
may aid in accounting for the excess of the September mor- 
tality over that of June, but it is, probably, mainly due to 
cases of disease contracted during July and August, which 
have assumed a chronic form, many even running into Octo- 
ber. The early days of September are usually hot enough to 
protract recovery and augment the danger, but the nights are 
cool, and the monthly mean for any series of years (58.30° in 
Philadelphia and 64.9° in New York for a series of seven 
years) is too low to be considered a heat factor in the causa- 
tion of diarrhoeal diseases. A continuous high temperature, 
represented by high daily maxima, high monthly mean and 
duration, does not offer a satisfactory explanation. For dur- 
ing some years, at some localities, the highest mortality oc- 
curs in June with a mean temperature less than either July 
or August. Dr. Harris says 2 "the month of June, like the 
month of November, in New York, is conspicuously the most 
healthy month of the half-year to which it pertains. Mean 
temperatures of from 68° to 70° F. in June, and of 42° to 
44° iu November, seem to be almost equally favorable to life 
and health, so far as immediate results are concerned among 
the inhabitants of this city." The following comparison (see 
Table VII.) of the mortality under five years of age in the 
city of Baltimore, with the mean monthly temperature for 
the years 1875, 1876, lb77, and 1878, exhibits a very differ- 

1 Report of Board of Health, New York, 1873, page 238. 

2 Report of Board of Health, New York, 1873, page 160. 



THE MORTALITY OF YOUNG CHILDREN. 



71 



ent condition in that city from that which is shown to be the 
case in the cities of Philadelphia, New York, and Boston. 

TABLE VII. — Comparing the Mortality of the Months of June, July \ 
August, and September, of Children under Five Years of Age, in 
the City of Baltimore, and the Mean Monthly Temperature, for the 
Tears 1875, 1876, 1877, and 1878. 





1875. 


1876. 


1877. 


1878. 


Month. 


Mortal- 
ity. 


Mean 
Temper- 
ature. 


Mortal- 
ity. 


Mean 
Temper- 
ature. 


Mortal- 
ity. 


Mean 
Temper- 
ature. 


liy - ature. 


June 

July 

August .... 
September . . . 


415 
614 
375 
292 


73.7° 
78 

73.41 
65.9 


657 
523 
411 
258 


75.9° 
80.4 
75.9 
65.6 


501 
597 
436 
310 


73.7° 
78.7 
77.6 
67.9 


365 
344 
313 
226 


70.1° 
80.8 
76 
69.3 



If continuous high temperature and duration of summer 
heat were the predominant and constantly prevailing agencies, 
the maximum mortality should have occurred in August, 
whereas it is less in each of the four years for that month than 
in either June or July. And if heat alone was the acutely 
active influence, then the July mortality should have uni- 
formly exceeded that of either of the other months ; yet with 
a higher monthly mean temperature for each of the four years 
than the other months, its mortality in 1876 and 1878 was 
even less than that of June of the corresponding years. Dur- 
ing the series of four years the mortality of June exceeded 
annually that of August, notwithstanding the mean tempera- 
ture was less. A careful examination of the table (VII.) shows 
the constancy of the heat factors, but there must be some ad- 
ditional relation of solar heat, other than those previously 
named, which exercises a potential influence at Baltimore, in 
the month of June. In 1875, a heated term began at Balti- 
more on the 24th of June with a maximum temperature of 
96°, and continued into the month of July. Practically it may 



72 THE MORTALITY OF YOUNG CHILDREN. 

be said to have lasted through the entire month of July, which 
for that year exhibits a mean of 78°. In 1876 a period began 
on June 24th, with a temperature of 90°, which extended 
into, and was followed by a second one, in July ; in 1877 the 
temperature rose suddenly on the 29th of May, and continued 
high throughout June, but there was no exacerbation accord- 
ing to the standard (in Table II.) adopted by the Signal 
Office, and but a short one in July, occurring as late as the 
25th. June, 1878, was a temperate month with a mean of 
70.1°, followed by two exacerbations in July. These data, 
compared with the mortality records, lead to the conclusion 
that sudden elevations of the temperature above the normal 
for July, at any locality, are specially detrimental to infantile 
life. Every fact connected with these meteorological observa- 
tions corroborates this conclusion. This sudden elevation 
seems to be the potential agency which characterizes July at 
Philadelphia, New York, Boston, and other populous cities of 
the northern and western climatic zones, as the most fatal 
month of the year to children, and the most conducive to 
bowel diseases. 

During the year 1872 the mortality of children under five 
was extraordinary during the months of June, July, and Au- 
gust in the cities of Philadelphia, New York, and Boston. 
To ascertain if this high death-rate could bear any relation to 
the exacerbations of temperature, the following data (Table 
VIII.) were obtained from the Signal Service Bureau. An ex- 
amination of the statement exhibits the fact that in each of 
the three cities there occurred two exacerbations during the 
month of June of that year, the last one of which, extending 
into the month of July, was followed by one or more during 
the latter month, and three during the month of August at 
each locality. It thus appears that, at these cities, during 
this year, the periods were unusually frequent and severe, re- 
curred at short intervals, and continued with unabated inten- 
sity until their cessation near the close of the month of Au- 
gust. So far, then, as the data are at command, the opinion 
previously expressed, in regard to the detrimental influence 



THE MORTALITY OF YOUNG CHILDREN. 



73 



of the periods of unusual high temperature, is fully con- 
firmed. 

TABLE VIII. — Statement showing the Periods in the Months of 
June, July, and August, of the Year 1872, during which the Tem- 
perature of the Air rose Ten Degrees, or more, above the Normal 
for July, at Boston, Mass., New York City, N. Y., and Philadel- 
phia, Penn., as recorded at the Stations of Observation of the Sig- 
nal Service, TJ. S. A., at those Places, 

[Compiled from the Records on file at the Office of the Chief Signal Officer, 
U. S. A., Washington, D. C] 



Boston 


Mass. 


The Normal for July, with ten 


degrees added, is 81.8°. 


Date. 


Highest Temp. 


June 12 


93° 


13 


84 


14 


88 


2S 


91 


29 


93 


30 


93.5 


Julv 1 


98 


2 


92 


3 


91 


4 


98.5 


5 


92 


6 


89 


7 


91 


8 


82 


9 


89 


10 


90 


11 


90 


12 


92 


13 


82 


14 


87 


15 


92 


16 


92 


17 


86 


19 


88] 


20 


87 


21 


87 


August 6 


87 



New York City, N. Y. 

The Normal for July, with ten 
degrees added, is 84.3°. 



Date. 


Highest Temp. 


June 


20 


86° 




21 


86 




22 


87 




28 


88 




29 


88 




30 


94 


July 


1 


95 




2 


*94 




3 


90 




4 


90 




5 


90 




6 


86 




7 


85 




13 


89 




14 


86 




15 


86 




16 


85 




17 


87 


August 


11 


86 




12 


88 




13 


85 




14 


90 




15 


89 




17 


85 




18 


85 




19 


89 



Philadelphia, Penn. 


The Nor 


mal for July, with ten 


degrees added, is 86.3°. 


Date. 


Highest Temp. 


June 


21 


*86° 




22 


*91 




23 


*86 




27 


*87 




28 


*87 




29 


*89 




30 


*92 


July 


1 


*94 




2 


*96 




3 


*96 




4 


*92 




5 


*89 




6 


*87 




9 


*86 




10 


*89 




11 


*86 




16 


*89 




17 


*88 




18 


*92 


August 


9 


87 




10 


88 




11 


90 




12 


91 




13 


92 




14 


91 




15 


89 



* Record of the highest exposed thermometer, there being no maximum in use. 



74 



THE MORTALITY OF YOUNG CHILDREN. 



TABLE VIIL, Continued. 



Boston. Mass. 


New York Citt, X. T. Philadelphia, Pbhw. 


( Continued.) 


( Continued.) ( Continued.) 


The Normal for Julv, with ten 


The Normal for Julv, with ten The Normal for Julv. with ten 


degrees added, is 81.8°. 


degrees added, is 843 d . degrees added, is 86.3 d . 


Date. 


Highest Temp. 


i 
Date. Highest Temp. Date. 


Highest Temp. 


August 7 


89° 


August 22 


91° 


August 21 


86.5° 


8 


94 


23 


85 


22 


92.5 


9 


95 


24 


84 


23 


86.5 


10 


90.5 










11 


86 










13 


89 










14 


83 










15 


92 










17 


86 










18 


87 










19 


91 
1 










22 


85 










23 


87 










24 


84 










25 


87 










26 85 









The greater prevalence and higher mortality of diarrhoeal 
diseases in July, which are always studied in connection with 
the uniformly higher mean temperature of the month, has led 
to the common error that a continuous high temperature, 
which is popularly and erroneously believed • to be expressed 
by a high monthly mean, is the predominant and distinctive 
influence in the causation of the summer diarrhoeas of infants. 
As yet no one but Professor Davis 1 has ventured to question 
the correctness of this almost universally accepted opinion. 
Any conclusion in regard to the causal relation of heat to dis- 
ease, deduced from the comparison of high monthly mean tem- 
peratures with high mortalities, must necessarily be fallacious. 
Very different temperature curves may be represented by the 
same monthly mean. A month of high day maxima and low 
night minima, or one with nearly uniform day and night tem- 

1 See paper on Climate and Disease, by Professor Abbe, published in 
Nat. Bd. Health Bull., vol. ii., Xo. 3. July, 1880. 



THE MORTALITY OF YOUNG CHILDREN. 75 

peratures, or one with acute exacerbation lasting for several 
days and nights and recurring several times, with intervals of 
greatly reduced temperature, might exhibit the same mean. 
If such months should show corresponding high means and 
high mortalities, still the relation of uniform high tempera- 
tures as the cause and excessive mortality as the effect would 
not be established, as is the general interpretation, for in fact 
the mortality occurred on clays or was grouped in periods, cor- 
responding at one time with a sudden ascent and at another 
with even a more marked fall of the temperature. The same 
mean may represent the same month at one locality with a 
very slight and at another locality with a very wide range of 
temperature, yet the mortalities will differ very greatly at the 
different localities ; and at the same locality the corresponding 
months of different years, even though the mean may be the 
same, will furnish very different percentages of deaths from 
the bowel diseases. If a climate represented by a mean 
monthly temperature varying from 70.4° to 73.6° for the hot- 
test month during a series of seven years, 1867-1875, is so 
conducive to bowel diseases and detrimental to infantile life at 
Boston, why should the same range of mean be a less poten- 
tial agency at Philadelphia, or afford comparative exemption 
from those diseases at New Orleans ? Similar comparison 
may be made between different cities with corresponding 
monthly means with like unequal mortality results. A care- 
ful analysis of the foregoing temperature and mortality statis- 
tics of the several cities absolutely invalidates the prevalent 
belief that a temperature uniformly above the July normal 
at any locality is the meteorological influence most conducive 
to intestinal disorders or detrimental to infants. If there was 
no other circumstance, the fact, admitted by all, that those 
diseases are less prevalent and less fatal in the cities border- 
ing on the Gulf of Mexico, 1 should be conclusive, as in these 

1 According to the statistics of Dr. Gibbons, Jr., Health Officer for San 
Francisco, in 1873, the ratio of death from cholera infantum in children 
under two years of age was in San Francisco only 5 in even 10,000 of the 
population, and in New Orleans only 7 ; while it was 24 in Boston, 25 in 
Brooklyn, 34 in Chicago, and 21 in Omaha. 



76 



THE MORTALITY OF YOUNG CHILDREN. 



cities the season of high temperature begins earlier and lasts 
longer, and the temperature is more continuously above the 
July normal, with less daily range and fewer violent fluctua- 
tions, either of ascent or descent. In corroboration may be 
cited the following additional facts : the lesser liability to and 
mortality from those diseases in the sparsely populated rural 
districts than in the city adjacent, which must be subject to 
the same meteorological conditions; the same relative infre- 
quency of sickness and death among the well-to-do-class, who, 
as the indigent and laboring classes of the same city, suffer 
like influence of the solar heat; and the marked increase of 
the diseases and mortality among the negro race in the South- 
ern cities since the emancipation, who now, as before the war, 
live in a region of continuous high temperature. To prove 
the utter fallacy of the opinion that continuous high tempera- 
ture is the predominant and potential influence causing these 
diseases, the following data (Table IX.) have been collected 

TABLE IX. — Showing the Ratio of Mortality from Cholera In- 
fantum to every 10,000 of the Population for 1873, in the Cities 
named, and the Monthly Mean Temperature and Range for the 
Months named in the same Tear at the same Places ; and also show- 
ing the Latitude, Elevation, and Rainfall. 



Ratio of Death in every 10,000 of population . 

Mean temperature of May 

Range of temperature for May 

Mean temperature for June 

Range of temperature for June 

Mean temperature for July 

Range of temperature for July 

Mean temperature for August 

Range of temperate for August 

Mean temperature for September 

Range of temperature for September .... 

Latitude 

Elevation of barometer above sea level, in feet . 
Annual rainfall, in inches, for year endiDg Sep- 
tember, 1873 



5 
53.6° 
27° 
57.8° 
17° 
57.9° 
22° 
59.1° 
18° 
57.8° 
16° 
3S°47' 
60 

15.66 



73.7° 
23° 
80.1° 
15° 

82.4° 

20° 

81.2° 

18° 

78.8= 

21° 

29=58' 

55.81 

72.81 



24 
56.8° 
35° 
67.2° 
46° 
72.9 
41 o 

68.8° 
46° 
61.7° 
47.5° 
42°21' 
77.4 

46.76 



57 6° 
44° 
6S.9 3 
41° 



714= 

34° 

65.4° 

34 3 

40-42' 

165.60 

42.45 



34 

53.9° 
52= 
70.2° 
48° 
71.2° 
43° 
71.7° 
39= 
62.4° 
47° 
41-52' 
65 7° 

28.73 



21 
59 3 
49° 
74 4° 
42° 
75.7° 
43 3 
77.1° 
45° 
60.6 
61° 
41°16' 
1,045.69 

28.98° 



1 The data relating to temperature could not be obtained, and those of 
New York City have been substituted. 



THE MORTALITY OF YOUNG CHILDREN. 77 

from Dr. Gibbons's report, and the annual report for 1873 of 
the Signal Service Bureau. 

The ratios of mortality in the cities of San Francisco and 
New Orleans do not differ much. The former exhibits a uni- 
form low mean and moderate range, representing a mild and 
equable climate ; the latter exhibits a uniform high mean 
with a moderate range, representing a hot and equable cli- 
mate. Compare these climates, which seem, because of their 
constancy and equability, specially exempt from intestinal dis- 
orders, with the climates of the four other cities, in which the 
ratio of mortality varies from three to five times as great as in 
the hottest of the six cities. In each of the four cities, Bos- 
ton, Brooklyn, Chicago, and Omaha, the range of tempera- 
ture is high, and the monthly means rise rapidly, the elevation 
varying from 8.4° at Boston to 17.3° at Chicago, from May to 
June, again ascending in July, though less, and in August 
descending moderately at Boston and Brooklyn, remaining 
about the same at Chicago, but continuing to rise at Omaha. 
In September the descent is marked at all stations, and most 
at Omaha. This examination suggests that the equable cli- 
mates, either temperate or hot, are far less favorable to the 
production of the summer diarrhoeas of infants than the cli- 
mates subject to violent changes and sudden high elevations 
of temperature ; and conversely that a variable climate, sub- 
ject to acute exacerbations of temperature during a brief 
summer season, which characterizes the belt or climatic zone 
described by Professor Davis, is the meteorological condition 
most conducive to these diseases. In this connection, Professor 
Abbe, in discussing the relation of hot weather to cholera infan- 
tum, says : " For instance, examine the unprecedented mortal- 
ity from cholera infantum as given in the Philadelphia Report 

of 1872 The first feature that strikes the student, is 

the maximum mortality of July 6th to 13th. Next comes the 
fact that the equally hot or hotter periods in May 6-12, June 
6-14, August 7-15, and 17-27, and September 6-10, were not 
attended by any special increase, but rather a very decided 
decrease or absence of cholera infantum, whence we can infal- 



78 THE MORTALITY OF YOUNG CHILDREN. 

libly conclude that high temperature has, in itself, very little 
direct influence on the disease, and this becomes clearer when 
we reflect that the actual mortality occurs always some time 
after the disease has taken hold upon the child, and that the 
maximum mortalitj^ of July 6th occurred two weeks after the 
remarkably sudden fall of temperature that is shown to have 
occurred on June 22d and 24th." The conclusion reached 
by Professor Abbe, who has studied the relation of climate 
to disease as a meteorologist, is the logical deduction from the 
premises stated, and is important, especially in so far as it 
points to the variations of temperature as the setiological fac- 
tor. The precise statement that the beginning of a large pro- 
portion of the cases is coincident with the sudden fall of the 
temperature of a heated period, is not entirely new. The 
observation is quite common among physicians that the acces- 
sion of new cases occurs quite frequently in groups coincident 
with the sudden termination of such a period. The writer, as 
early as 187 3, 1 advanced that view, which he believes has 

1 In 1873 lie wrote as follows: " The disturbance of the normal relation 
subsisting between the skin and intestinal mucous membrane is another 
important element of causation. This fact has been universally conceded 
by writers upon the diarrhoeal complaints of adults, but among pasdiatricars 
it is only casually enumerated in their multitudinous array of influences. 
The physiological antagonism between the cutaneous and intestinal secre- 
tions is so manifest that it is not difficult to understand why the suppres- 
sion of the former should determine an alvine flux. It may not only im- 
pose additional functional activity upon the intestinal mucous membrane, 
to relieve the system of accumulated fluid, but also to effect the elimination 
of effete matters, and thus local irritation, hypersecretion, increased peri- 
staltic action, and alvine flux may find their immediate and direct cause. 
The manifest effect of the sudden arrest of the cutaneous transudation, as 
the most frequent cause of the cases occurring during the autumn, win- 
ter, and spring months, is apparent, even to the most casual observer, and 
I apprehend that it is far more frequently the immediate influence during 
hot weather, especially in moist localities and during rainy seasons, than 
is generally believed. I have uniformly observed an accession of disease 
and frequent relapses following the sudden and violent lessening of tem- 
perature which so frequently terminates our brief heated terms, and more 
especially so if accompanied with moist and rainy weather." (Columbia 
Hospital Report, 1873, page 346.) 



THE MORTALITY OF YOUNG CHILDREN. 79 

been confirmed by a more extensive and careful observation, 
and by a more recent study of the causal relations of tem- 
perature. This opinion is in entire accord with the general 
effects of temperature. An endurable temperature deranges 
health either by its long continuance, or by sudden variations. 1 
In climates of uniform extremes of temperature, the greatest 
mortality, from all causes and of all ages, usually occurs in 
the coldest, and the least in the warmest months. The num- 
ber and nature of diseases produced by the varying conditions 
of the temperature differ in various localities, but nowhere 
does the maximum occur in winter. The organism suffers 
more often and more severely from the sudden changes than 
from the long continuance of either extreme heat or cold. 
The phenomenon is called " catching cold." The effect is 
severe in proportion to the rapidity of the motion of the dif- 
ferently heated airs, or as it may strike upon portions of the 
body exposed or insufficiently protected, or when perspiring. 
No one doubts the influence of refrigeration, or " catching 
cold," in producing catarrhs of the mucous membrane, most 
frequently of the respiratory organ in the winter season, and, 
perhaps, quite as often of the intestinal tract in the summer 
season. The relation of the chilled surface to the organs is 
also important. Chilling of the neck causes catarrh of the 
windpipe ; of the chest, bronchitis ; and of the abdomen, diar- 
rhoea. But more important in this connection, is the well 
recognized principle in setiology, that in every organism the 
tender part will become diseased, no matter where the chilling 
may have acted. Whatever, then, may be the morbid tend- 
ency or liability to a special disease, the sudden refrigeration 
of the body or any part of it is conducive to its development. 
The complex conditions of alimentation and digestion, which 
so constantly imperil the life of infants at all seasons of the 
year, exposes the alimentary tract especially to the detri- 
mental influence of the rapid fluctuations of day and night, or 
of winter and summer. In the colder season, infants are pro- 

1 Manual of General Pathology, Wagner, page 60, from which these 
general observations have been condensed. 



80 THE MORTALITY OF YOUNG CHILDREN. 

tected from the changes of the weather ; the colder, the more 
careful the protection, especially of the trunk and limbs ; but 
it is not always possible so to temper the air as to protect the 
respiratory apparatus. Hence the greater prevalence of dis- 
eases of these organs in winter, even if there were no cases 
of neglect, improper exposure, or insufficient clothing. Sud- 
den refrigeration of the surface by rapid fall of the tempera- 
ture will affect infants more often and quite as seriously during 
the season of summer heat. A temperature which is delight- 
ful in summer is oppressive in winter, and one which would 
make winter agreeable would be cold in summer. The body, 
by continued exposure to an endurable temperature, acquires 
a habit which is disturbed by a sudden variation. The winter 
and summer seasons, as they occur in this country, are not 
unfavorable to the performance of all the functions, because 
the organism accommodates itself to such ordinary changes as 
are not excessive. Heat production is lessened in summer 
and increased in winter, so that the body heat is uniform dur- 
ing the different seasons. An elevated temperature warms 
and moistens the skin, quickens the respiration, and acceler- 
ates the heart. The perspiration varies according to external 
temperature and exercise. A draught of air, striking upon a 
moist surface, produces greater refrigeration of the part, and 
its influence upon the tissues of the skin, and nerves in par- 
ticular, must be more intense than if it had been passed over 
a dry surface. Then, too, the chilling of the surface may 
arrest the cutaneous exhalation, and may, also, through reflex 
action, extend its perturbations to internal organs. A sudden 
fall of the temperature during an epidemic of yellow fever 
will surely arrest the spread of the disease, and will, with 
almost equal certainty, prove injurious and even fatal to many 
suffering from the disease at the time ; and chilling will fre- 
quently reproduce an intermittent fever in one who has been 
long removed from the influence of the miasm. In cholera 
seasons many persons are attacked after sudden chilling of 
the body. The catching of cold is an undoubted astiological 
fact, of the truth of which everybody ought to be convinced, 



THE MORTALITY OF YOUNG CHILDREN. 81 

but that the fall of the temperature is more potential than 
the exacerbations of heat in the causation of the diarrhoea! 
diseases of infants has not been clearly established. It is true 
that in those cities throughout the climatic region of this 
country where infantile diarrhoeas are most prevalent and 
fatal, the fluctuations of the temperature during the brief 
summer season are most acute and intense, and there seems 
to be a correspondence in the percentages of mortality and 
the frequency and violence of these temperature variations. 

Most authors maintain the predominance of the heat factors ; 
and Professor Davis, as previously stated, insists that the 
clinical records at his command show a correspondence be- 
tween the initial symptoms of the bowel affections and the 
groups of days and nights of excessive heat, and " that the 
degree of prevalence and fatality of such diseases will be in 
direct ratio to the intensity and duration of the heat waves 
occurring between- the middle of June and the middle of Au- 
gust." Of the deleterious influence of the heated periods 
upon infantile life there cannot be a doubt. The assertion 
that acute elevation of the temperature, lasting for several 
da} T s, and rapid fall are agencies operating alike upon infan- 
tile life, which are both conducive to the development of 
diarrhceal diseases, seems absurd, yet it may be true. Un- 
fortunately, the data which might determine the causal rela- 
tion* of the two elements, the sudden increase and the sudden 
diminution of heat, are not accessible. Professor Davis has 
made an effort to supply the deficiency by collecting statistics 
from Davenport, Omaha, Cairo, Dunkirk, and Chicago, which 
show a correspondence between the beginning of the cases 
of disease and the periods of excessive heat. This is the 
only correct way of studying this question. Until it is gen- 
erally practised by physicians the decision will remain unset- 
tled. 

Two grave errors pervade every attempt to study the rela- 
tion of cause and effect between meteorological phenomena 
and infantile diarrhoeas. The first consists in the comparison 
of mortality statistics with the prevailing condition of the at- 



82 THE MORTALITY OF YOUNG CHILDREN. 

mospliere, when the comparison should properly be made be- 
tween such conditions and the actual number of cases of sick- 
ness beginning coincident with, and their course and progress 
during the continuance of, such conditions. In short, the 
meteorological influences should be studied in connection with 
the clinical histories, and not exclusive^ with the fatal re- 
sults. Until this is done the prevailing doubts and diversities 
of opinion will continue to obstruct the acquisition of relia- 
ble information. The second error relates to the improper 
and careless record of the precise nature of the disease. The 
deaths of infants from bowel affections are usually recorded 
under the classifications of cholera infantum, diarrhoea, entero- 
colitis, and dysentery, which excludes a great number of 
deaths which should be included ; but the improper applica- 
tion of these names is the more serious mistake. Cholera in- 
fantum is a diarrhoea; but a simple inflammatory or non-in- 
flammatoiy diarrhoea is not a cholera infantum. All authors 
and careful diagnosticians recognize the very marked clinical 
distinction between the choleraic and diarrhoea! affections of 
infants, and very properly so, for the histoiy, progress, treat- 
ment, and mortality differ very widely. Nevertheless, the 
mortality statistics, as reported by the health officers of the 
various cities, either classify every form of bowel complaint 
under the head of cholera infantum, or else the number of the 
cases is so magnified by the misapplication of names as to con- 
vey the impression that this one disease is the scourge which 
annually decimates the infantile population of large cities ; yet 
every observing and qualified physician knows that the chol- 
eraic forms, though more fatal, are far less in number than 
the simple non-inflammatory diarrhoeas. The sanitarium Avill 
contribute materially to the study of these clinically differ- 
ent diseases, by requiring the record of the precise character 
of the initial symptoms, as well as the course, progress, and 
treatment of each case both before and during its residence in 
the domiciliary department. By such means facts may be 
reached which will determine the relation of meteorological 
influences to the causation and mortality of the several forms 



THE MORTALITY OF YOUNG CHILDREN. 83 

of infantile bowel complaints. Especially important is it to 
ascertain the predominant influence, if there be any, and the 
relation it may bear to the clinically distinct forms of diar- 
rhoea. This information is of paramount importance, for the 
methods of prevention, to be successful, must comprehend a 
full knowledge of the cause. Very different means, appli- 
ances, and perhaps, differently arranged buildings will be re- 
quired, according as the heat exacerbations or chilling may be 
the immediate or acute agency producing one or all of the 
several forms of disease. For it is probable that the varying 
atmospheric conditions of excessive heat and sudden cooling 
may bear definite relations to the causation of the different 
forms. Overheating of the body produces effects unlike those 
following chilling. A high temperature interferes with the 
radiation of body heat, and the nearer the external heat ap- 
proaches that of the body the more heat is retained, unless 
the heat-wasting functions become more active. The organ- 
ism, especially of infants, which may have become habituated 
to the ordinary diurnal changes of summer heat at any given 
locality, can neither accommodate itself to the rapid loss of 
heat when the temperature suddenly falls, nor to the arrest of 
heat radiation when the sudden exacerbations occur and con- 
tinue for two or more days. In either case injury follows, but 
it would be contrary to the general law of causation, that the 
resultant diseases should be identical. It may be, as would 
seem to be the natural order of events, that the choleraic 
forms, in a measure at least, owe their origin to the overheat- 
ing, and the catarrhal forms to the chilling processes. The 
sanitarium will possess opportunities and facilities, never be- 
fore offered, to settle this important question. 

To recur to the statement that daily mortalities from in- 
fantile bowel affections bear no constant relation to the days 
of excessive high temperature, but vary from day to day dur- 
ing the season of summer heat and violent fluctuations of tem- 
perature, and more fully to exhibit the fallacy of studying 
cause by comparison of mortalities with the prevailing meteor- 



84 THE MORTALITY OF YOUNG CHILDREN. 

ological conditions the following data (Table X.) have been 
supplied by the Health Officer of the District of Columbia. 1 

The comparison should be made between the daily- mortal- 
ities as shown in Table X. and the corresponding days of the 
periods of excessive heat, as shown for Washington in Table 
No. II. ; and also between the days on which sudden falls of 
temperature occurred, as shown in the annual reports of the 
chief signal officer and the daily mortalities. The examina- 
tion will show that mortalities, large for Washington, will 
sometimes occur simultaneously with hot days and hot periods, 
and sometimes with cool days and cool periods, and then run 
along quite evenly for days without regard to the temperature 
changes ; but there is more frequent correspondence between 
high mortalities and hot periods than with other conditions. 
The same is true of New York, and perhaps of other cities. 
These facts reassert the predominant influence of excessive 
heat, and suggest the possible hypothesis that the succeeding 
exacerbation is specially detrimental to the cases commencing 
during the immediately preceding period of greatly lessened 
heat ; and this coincides with the clinical fact, that infants 
moderately sick with simple diarrhoea frequently grow sud- 
denly and rapidly ill, with profuse liquid stools, during a day 
of excessive heat. 

1 More properly the data should have been obtained from Baltimore 
city, but the application was refused, because of insufficient clerical force 
and inadequate means. Washington was then selected, because it was the 
nearest large city, and did not differ materially in temperature and other 
meteorological conditions. Dr. Mead, under the direction of his superior, 
very promptly and courteously complied with the request. An opportunity 
is thus offered to show to the country that this city, so unjustly assailed 
for the insalubrity of its climate, is the most favorable summer residence 
for young children of any city of equal or greater population north of the 
Potomac River. The mortality data are absolutely correct and include sev- 
eral diseases usually omitted from the death-rates from infantile bowel 
affections. The comparatively small mortality in a population of 177,638 
(of which 59,402 are negroes) must bear a definite ratio to the number of 
cases, or else the treatment is unusually successful. Its wide and clean 
streets and numerous parks contribute both to its healthfulness, and to the 
successful management of the cases of sickness. The excess of mortality 
under one year is, however, as conspicuous here as elsewhere. 



THE MORTALITY OF YOUNG CHILDREN. 



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Number of deaths 3 to 5 years . . . 
Total deaths of children under 5 years 

Number of deaths under 1 year . . . 
Number of deaths 1 to 2 years . . . 
Number of deaths 2 to 3 years . . . 
Number of deaths 3 to 5 years . . . 
Total deaths of children under 5 years 

Number of deaths under 1 year . . . 
Number of deaths 1 to 2 years . . . 
Number of deaths 2 to 3 years . . . 
Number of deaths 3 to 5 years . . . 
Total deaths of children under 5 years 

Number of deaths under 1 year . . . 
Number of deaths 1 to 2 years . . . 
Number of deaths 2 to 3 years . . . 
Number of deaths 3 to 5 years . . . 
Total deaths of children under 5 years 


June, 
1876. 

July, 
1876. 

Aug. 
1876. 

Sept. 
1876. 



86 



THE MORTALITY OF YOUNG CHILDREN. 



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THE MORTALITY OF YOUNG CHILDREN. 



87 



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Number of deaths 1 to 2 years . . . 
Number of deaths 2 to 3 years . . . 
Number of deaths 3 to 5 years . . . 
Total deaths of children under 5 years 

Number of deaths under 1 year . . . 
Number of deaths 1 to 2 years . . . 
Number of deaths 2 to 3 years . . . 
Number of deaths 3 to 5 years . . . 
Total deaths of children under 5 years 

Number of deaths under 1 year . . . 
Number of deaths 1 to 2 years . . . 
Number of deaths 2 to 3 years . . . 
Number of deaths 3 to 5 years . . . 
Total deaths of children under 5 years 

Number of deaths under 1 year . . . 
Number of deaths 1 to 2 years . . . 
Number of deaths 2 to 3 years . . . 
Number of deaths 3 to 5 years . . . 
Total deaths of children under 5 years 

Number of deaths under 1 year . . . 
Number of deaths 1 to 2 years . . . 
Number of deaths 2 to 3 years . . . 
Number of deaths 3 to 5 years . . . 
Total deaths of children under 5 years 

Number of deaths under 1 year . . . 
Number of deaths 1 to 2 years . . . 
Number of deaths 2 to 3 years . . . 
Number of deaths 3 to 5 years . . . 
Total deaths of children under 5 years 


1878. 

Sept. 
1878. 

June, 
1879. 

July, 
1879. 

Aug. 
1879. 

Sept. 
1879. 



88 THE MORTALITY OF YOUNG CHILDREN. 

The foregoing analysis leads to several important and defi- 
nite conclusions : — 

(1.) The month of July is the hottest and sickliest month 
of the year, most conducive to bowel affections, and most fatal 
to children under five years of age. 

(2.) The epidemics of bowel affections of children, incident 
to the summer season, have their beginning nearly simulta- 
neously with the first exacerbation of heat, which usually oc- 
curs in the latter half of June ; and the maximum daily mor- 
talities more frequently correspond with the maximum tem- 
peratures, which occur in periods of three or more days, at 
longer or shorter intervals during the summer months. 

(3.) With the usual lowering of temperature and absence of 
excessive heat periods, which occur after the middle of August, 
the daily mortality declines. 

(4.) The detrimental influence of summer temperature is 
intensified by sudden and acute elevations and falls. 

(5.) Children under one year of age are most numerously 
and seriously affected by the temperature influences. 

If these conclusions are correct, the effort to diminish mor- 
tality among children must direct itself mainly to the preven- 
tion of the diarrhceal complaints of infants under one year of 
age. To accomplish this it becomes of paramount importance 
to protect them from the influences of excessive heat, and 
from the violent fluctuations of temperature, which occur so 
suddenly during the summer season in the geographical re- 
gion where these diseases are so prevalent. In the neighbor- 
hood of the city of Baltimore there are elevated localities 
which will have a temperature two or three degrees below 
that of the city, and where, in properly constructed and ar- 
ranged buildings, freer ventilation, purer air, and less crowd- 
ing may be secured, and from these latter as much advantage 
may result as from the former. When necessary, artificial 
means may be employed to promote and increase the move- 
ment, and diminish the temperature of the surrounding air ; 
and where, in special cases, remedial agents and a variety of 
measures pertaining to personal and domiciliary hygiene may 



THE MORTALITY OF YOUNG CHILDREN. 89 

be used to lessen body heat. A sanitarium properly located, 
with suitable buildings, supplied with the necessary appoint- 
ments and under expert management, may accomplish much 
towards modifying the deleterious influence of temperature 
conditions, hitherto regarded as an irremediable cause of in- 
fantile diarrhoeas. 

Heat exhibits its deleterious influence in another and very 
important relation. It is one of the many conditions which 
in conjunction make up a season. The change from winter 
to summer is characterized by increased solar heat ; the suc- 
cessive stages of growth, maturity, and decay in the vegetable 
kingdom ; the generation of spores ; the reproduction of myr- 
iads of animalcular insects and parasites, and the rehabilita- 
tion of torpid life ; the setting up of putrefactive processes ; 
the generation of noxious effluvia and their diffusion in the 
air ; the changed condition of animal life ; the more constant 
exposure of human beings to the air ; the altered habits and 
mode of life of all classes of people ; the introduction of new 
foods into the dietary which undergo rapid change and de- 
cay ; and the greater carelessness in personal protection and 
hygiene. All these cooperating elements must influence the 
organism, especially of the nursing infant and fostering 
mother. 

An examination and comparison of the statistics of the 
weekly mortality from diarrhceal diseases, in the cities 
grouped according to latitude, as shown in the table below 
(Table XI.), will exhibit the gradual increase of these diseases 
with the gradual advance of the summer solstice northward 
until it reaches its maximum during the period when all the 
elements which complete the season of summer are in their 
fullest activity ; again gradually to decline with the return to 
the winter season, the period of rest, hibernation, or death of 
the lower organisms, and of suspension of vegetable growth and 
of decay and putrefaction, — the period when the diet is more 
uniform and consistent, and life is, in a measure, freed from 
the evanescent irregularities incident to the discomfort of high 
temperature, and from the indiscretions of diet which are so 



90 



THE MORTALITY OF YOUNG CHILDREN. 



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THE MORTALITY OF YOUNG CHILDREN 91 

prolific of mischief during the season of abundant supply and 
rapid deterioration of fruits and vegetables. 

At first glance this table (XI.) would seem to show 
that there is a belt of territory, located between latitudes 38° 
and 41° north, in which, during the months of June, July, 
August, and September, there is a very high mortality from 
diarrhoeal diseases. But when the weekly mortality returns of 
the cities situated between these latitudes are compared with 
similar data from the cities of Boston and Chicago, the two 
largest cities north of this belt, it becomes manifest that the 
density of the population is a more potential factor than lati- 
tude. The influence of longitude must be inconsiderable, or 
else it exhibits an inconstant agency, for the mortalities of 
cities located in or near the same longitude, but in distant lat- 
itudes, bear no uniform relation under other like conditions. 

The influence of climate is also shown. New Orleans, 
which is situated in latitude 29° 59', exhibits a slightly higher 
mortality rate than San Francisco. The former is the 
most southerly of the Gulf cities, and the latter is far re- 
moved, in latitude 37° 47', towards the west, on the Pacific 
coast. Both of these cities are located in equable climates, 
but the higher mean temperature of New Orleans corresponds 
with the higher (see Table IX.) mortality of that city. The 
slightly different and low mortality rates of these two cities, 
are, however, in marked contrast with the very high death- 
rates of cities subject to very wide ranges and sudden fluc- 
tuations of temperature. 

The total movement of the wind is, perhaps, a more im- 
portant influence than is generally believed. Data supplied 
from the Signal Office for each month of the years 1875, 
1876, 1877, 1878, 1879, and 1880, show that the monthly 
movement of the wind, in miles, at the cities named in Table 
XI. (excepting San Francisco), is less during the months of 
June, July, August, and September, for each of the years enu- 
merated, than during any other four consecutive months, and 
with an occasional exception, is less during either of these 
months than during any of the other months of the year. New 



92 THE MORTALITY OF YOUNG CHILDREN. 

Orleans represents a station in an equable temperature with 
high range, and medium movement of wind, and San Francisco 
a locality with lesser range of temperature but much larger 
movement of wind. These uniform climates, though differing 
in ranges of temperature and total monthly movement of 
wind, exhibit low death-rates from the summer diarrhoeas, 
the lower rate corresponding with the more moderate temper- 
ature and larger movement of wind. ^San Francisco is, how- 
ever, an exceptional locality, due probably to meteorological 
conditions common to the Pacific coast. East of the Rocky 
Mountains the relation of the movement of the wind to 
the summer mortalities is very different. A comparison of 
the mortality data in Table XI. with the records of the 
monthly movement of the wind for the years previously named 
shows : — 

(1.) July to be the month of greatest mortality and least 
movement of wind. 

(2.) The nearer the monthly movements of wind approach 
uniformity, the less the mortality from summer diarrhoeas. 

(3.) Equability of climate corresponds with uniformity and 
moderate or small monthly movements of wind and small mor- 
talities. 

(4.) Wide ranges of temperature correspond with large 
movements of wind and high mortalities from summer diar- 
rhoeas. 

(5.) Weekly mortalities from diarrhoeal diseases increase 
correspondingly with advance of the summer solstice north- 
ward, increasing and greater range of temperature, and larger 
and more fluctuating movements of wind. 

The table exhibits also the influence of race characteristics. 
The death-rates of the negro race, as reported, are in many 
localities phenomenal and read like a fiction of the Munchau- 
sen style. That the mortality is generally greater than of the 
white race is an indisputable fact. This fact may account for 
the high death-rates in Baltimore, Charleston, Savannah, Dis- 
trict of Columbia, and most Southern cities, but it is inex- 
plicable why the death-rate of the negro race in some cities 



THE MORTALITY OF YOUNG CHILDREN. 93 

should be much less than that of the white, and double and 
treble in other cities. 

The table exhibits furthermore the insalubrity of locality. 
The special endemic influence is not shown. It seems proba- 
ble that density of the population, mode of life, and occupancy 
of tenement houses, are the deleterious agencies. 

In this connection the element of acclimation deserves con- 
sideration. A climate may be defined to be (Wagner) the 
sum total of all influences derived from the soil and atmos- 
phere. Acclimation diseases are, apart from those which are 
endemic and infectious, nearly always gastric and intestinal 
catarrhal affections. It is a law of general aetiology that 
continuous residence of sufficient duration usually affords 
immunity from the climatic maladies. The comparative in- 
frequency of infantile diarrhoeas in the Southern cities of this 
country, where the general atmospheric conditions believed 
to be so conducive to their production so constantly prevail, 
suggests that acclimation is a protective influence, constantly 
operative in diminishing the tendency in infants to bowel 
maladies ; whereas, in the Northern cities, where the range of 
temperature between the extremes of winter and summer is 
so great, this immunity cannot be acquired by infants ex- 
cept through the perils of disease, to which thousands suc- 
cumb. The prevalent liability to bowel affections and the 
excess of mortality of infants under one year of age in the 
Southern as well as in the Northern cities, at all seasons of the 
year, may find an additional factor of causation in the un- 
acclimation to the surrounding medium, the temperature of 
which is so much lower than that to which intra-uterine life 
had become accustomed. The extraordinary susceptibility of 
the newly born to the variations of the temperature of the 
surrounding air is probably the most fruitful source of many 
of the preventable maladies of early life. 1 To this circum- 

1 " Infants have but feeble power of generating heat, and are absolutely 
dependent upon communicated warmth. And here I must enter my ear- 
nest protest against the custom of carrying newborn children from room to 
room, and even from house to house, for exhibition. I have no doubt that 



94 THE MORTALITY OF YOUNG CHILDREN. 

stance, perhaps more than to any other, is due the terrible 
mortality among those born out of wedlock, where motives of 
concealment interdict the necessary protection ; among the 
first-born, where the ignorance of attendants plays such an 
important part ; and among the poor, where destitution robs 
the babe of the needed wrappings and artificial warmth. In 
the domiciliary department the influence of this element may 
be satisfactorily studied, and mothers can be taught the value 
of pretention and the method of accomplishing the best re- 
sults. If these suggestions have any foundation in fact, the 
methods of prevention, to be effective, must begin in the lying- 
in chamber during the puerperal period, and be persistently 
carried out during the early months of life. 

HUMIDITY. 

The study of the relation of the humidity of the air to the 
causation of these diseases is attended with contradictions not 
unlike those which embarrass the study of the heat factors, 
and grow out of the mistake of comparing mortalities with 
the daily mean percentages of moisture. It is generally be- 
lieved that a high temperature with high relative humidity, 
low and damp localities, and damp dwellings, predispose to 
these diseases. This is partially true, but the statement that 
a high temperature and high humidity, independent of other 
accessory influences, bear any constant or uniform relation to 
the prevalence of these affections, cannot be maintained. The 
following analysis of the heated periods (Table XII.) will 
show that high humidity is not always coincident witli high 
maximum and high daily mean temperature. Mortalities do 
not show any constant correspondence with high maxima, 
high daily mean temperatures, and high percentages of rela- 
tive humidity. During L the heated periods of 1876-79 (see 

many of the obscure as well as familiar diseases of infants have their 
origin in this reprehensible practice. Nothing is more easy than for the 
sensitive surface to become chilled, and various congestive disorders to be 
thus induced." (Annie M. Hale, M. D., Management of Children, 1880, 
page 16.) 



THE MORTALITY OF YOUNG CHILDREN. 



95 



TABLE XII. — Shotting the Averages of the Maximum and Mean 
Daily Temperatures, and of the Mean Daily Humidity of the Air, 
during each of the Periods, at the Cities, and for the Years named. 





Baltimore. 


Chicago. 


N 


ew York. 


"Washington. 




Max. 


M. D. 


M. II. 


Max. 


M. D. 


M. H. 


Max. 


M. D. 


M. H. 


Max. 


M. D. 


M. H. 


1876. 


























June . . 


92.4° 


82.5° 


59.74 


85.63° 


79. 23° 


71.9 


88.28° 


78.72° 


61.24 


93.4° 


81.88° 


63.6 


July . . 


92-8 


82.9 


62.68 


92.25 


83.57 


67.4 


91 


81.11 


58.75 


93.3 


8*.04 


63.24 


July . . 


91.23 


84.71 


62.55 


_ 


_ 


_ 


91.16 


80.55 


62.38 


95.18 


84.62 


66.83 


July . . 




_ 


_ 


_ 


_ 


_ 


91 


81.22 


63.92 


04.37 


85.4 


63.07 


August . 


- 


- 


- 


87.33 


79.8 


67.56 


88 


78.47 


03.97 


91.66 


80.93 


71 


1377. 


























June . . 


_ 


_ 


_ 


_ 


_ 


_ 


86 


75.06 


53.02 


_ 


- 


_ 


July . . 


92.25 


182.3 


67.4 


88.66 


78.8 


70.52 


90 


81.05 


56.03 


94.87 


82.77 


69.6 


July . . 


_ 


_ 


_ 


;86 


78.23 


77.46 


_ 


- 


- 


- 


_ 


_ 


August 


- 


- 


- 


85.66 


75.06 


75 


88 


78.47 


65.07 


91.9 


81.18 


65.52 


1878. 


























June . . 


_ 


_ 


_ 


_ 


_ 


_ 


87 


78.56 


60.76 


_ 


_ 


_ 


July . . 


92.25 


82.77 


62.25 


86 


78.73 


74.03 


87.66 


77.65 


61.81 


99.95 


81.90 


67.96 


July . . 


94.3 


84.92 


64.94 


90.6 


83.32 


69.06 


87 33 


76.73 


76.56 


95.1 


84.4 


70.92 


July . . 




_ 


- 


- 


_ 


- 


91.33 


81.9 


67.2 


pi. 25 


- 


- 


August . 


- 


- 


- 


86 


74.96 


63.61 


86 


75.63 


68.43 


80.05 


69.41 


1879. 


























June . . 


_ 


_ 


_ 


86 


79.36 


60.03 


87 


76.96 


68.8 


m 


80.56 


63.2 


June . . 


_ 


_ 


_ 


- 


_ 


- 


_ 


- 


- 


y3.66 


81.8 


62.13 


July . . 


94.66 


85.5 


48 


90 


83.15 


61 


90.33 


79.2 


62 


94.83 


82.4 


50.3 


July . . 


_ 


_ 


_ 


_ 


_ 


- 


85.33 


77.13 


71.1 


05.37 


83.82 


51.17 


July . . 








- 












92.5 


82.03 


58.9 


August . 


90.8 


S2.65 


64 


88 

86.66 


85.53 


58.1 


88.66 


78.66 


52.42 


92.6 


81.72 


68.72 


August . 


- 


- 


- 


79.46 


59 


- 


- 


- 


~ 


- 


- 



Table II.) the maximum and daily mean temperatures were 
higher in Washington than in New York, but the percentages 
of relative humidity were nearly the same. If the combina- 
tion of excessive heat factors with high relative humidity 
were the special atmospheric condition so conducive to diar- 
rhoea! diseases, then the death-rate in Washington should have 
exceeded that in New York. The latter city, with an aver- 
age maximum temperature 5° less, exhibits an average per- 
centage of relative humidity nearly equal to that of Washing- 
ton. The percentage of humidity represents the ratio of 
moisture in a given volume of air, but the dampness of the 
air is the expression of the relative saturation to the amount 
it would hold if saturated. Air at 93° Fahr. is not so damp 
as air at a lower temperature but holding the same amount of 
moisture, because the higher the temperature the greater is 



96 THE MORTALITY OF YOUNG CHILDREN. 

its capacity for moisture. Excess of humidity with relation 
to heat is the condition so detrimental to the organism, and 
the more so when the temperature suddenly falls, as is illus- 
trated in the disturbance of important functions of the organ- 
ism and the chilling processes, to which reference has been 
previously made. It will be seen by examination of Tables 
II. and XII. that the relative saturation is greater in Chicago 
than in either of the four cities ; and least in Baltimore. But 
high temperature with high relative saturation cannot be ac- 
cepted as a universal factor. In the cities bordering on the 
Gulf the relative saturation is uniformly higher than in the 
cities of the northern climatic zone, yet the prevalence and 
mortality of bowel affections are vastly less. So it is in the 
rural districts and along the sea-coasts, yet these are favorite 
health resorts for children suffering with these maladies. 
There must be some condition of the air, not present in the 
farming regions or along the sea-coast, and only to a limited 
extent in the Gulf region, which is common to most of the 
densely populated cities, and to localities inhabited by the 
poor and destitute, which in combination with heat and moist- 
ure will complete the atmospheric environment. The various 
circumstances of life in a city, considered in reference to the 
prevalence of bowel affections, point clearly to the conclusion 
that moisture in relative excess to the heat of an impure and 
stagnant atmosphere is the condition which supplies the most 
satisfactory explanation of its detrimental influence. This 
conclusion becomes the more important in view of the fact 
that it is in entire accord with the accepted opinions concern- 
ing the deleterious influence of over-crowding; the diffusion of 
noxious effluvia in the air ; imperfect ventilation of dwellings, 
sleeping apartments, and cities ; the general unhygienic condi- 
tion of the homes ; and the personal uncleanliness of that class 
of the population of the city among which the summer diar- 
rhoeas are so fatal. It is furthermore corroborated by the 
prevalent opinion that low and damp situations, imperfectly 
drained localities, and damp dwellings, where the air is stag- 
nant and foul, are conducive to these diseases. And still 



THE MORTALITY OF YOUNG CHILDREN. 97 

more important is it that it directs attention to the necessity, 
as a means of prevention, of pure air, clean streets, clean and 
well-ventilated dwellings and sleeping apartments, personal 
cleanliness, less crowding in unfit dwellings, and diminished 
density of population. The proper construction of tenement 
houses and the proper adjustment of the number of residents 
to the area, together with the rigorous enforcement of sani- 
tary regulations, would greatly lessen the prevalence and mor- 
tality of the infantile summer diseases in cities, especially in 
those parts where over-crowding and filth prevail, and the air 
is laden with emanations from the soil saturated with human 
excrement. The nearer the surface the more damp, foul, and 
stagnant the air, the fewer the currents, and the greater the 
necessity for freer ventilation. 

The construction of one-story dwellings, and the occupancy 
of the ground and under-ground floors as sleeping apartments, 
especially in the densely populated districts of cities, should 
be prohibited by municipal ordinance. By compelling those 
who are prompted by their cupidity to provide the poorest 
accommodations at the highest rental, for those who cannot 
help themselves, to conform to definite plans of constructing 
tenement houses, 1 and a definite occupancy of space, the evil 
effects of over-crowding, bad air, and personal uncleanliness 
might be greatly lessened. In fact, law and force must be in- 
voked before the full measure of prevention can be obtained. 
It would be an act of wise economy, conducive to the wealth 
and growth of every municipality, and to the health and wel- 
fare of its citizens, if their governments assumed and enforced 
such authority. 

DENSITY OF POPULATION. 

The bad effects of density of population and over-crowding 
of habitations, together with the various contingencies of life 
in large cities, are so obviously manifest, and so universally 

1 Of the children under five years of age who have died during the 
week ending July 3, 1880, in New York, 66.85 per cent, were taken from 
tenement houses. (N. Y. Herald, July 8, 1880.) 

7 



98 



THE MORTALITY OF YOUNG CHILDREN, 



acknowledged, that any attempt at demonstration wonld be 
simply a work of supererogation. It is not, however, so gen- 
erally known that with the increase of the number of persons 
to the square mile the death-rate under five years increases in 
greater ratio than the death-rate at all ages. The following 
statement, constructed by Dr. Farr, shows the relation be- 
tween the death-rates at all ages and under five, and the 
density of population in a series of English districts : — 



TABLE XIII. 



Death-rate at All Ages. 


Death-rate under Five. 


Persons to One Square Mile. 


16 


37.80 


166 


19 


47.53 


186 


22 


63.06 


379 


25 


82.10 


1,718 


28.5 


95.04 


4,419 


32 


111.90 


12,357 


39 


139.50 


65,823 



The same is true of this country, as is shown by the census 
of 1860, 1870, and 1880. When to a superabundant and un- 
clean population are added the effects of an inadequate pro- 
vision for the removal of the various excreta, " the result is 
(Curtis) that the air is permanently laden with foul matters, 
comprising effluvia from the skin and lungs of the inhabi- 
tants, and noxious vapors and gases from sinks, gutters, and 
soil pipes, and, worse still, excrementitial molecules from 
choked up privies, drains, and sewers. Air reeking with these 
filthy matters requires only the ripening action of the mid- 
summer heat to be kindled, as it were, into a blaze of poison- 
ous putridity. When all these conditions are fulfilled, mias- 
mata are generated, which seem to concentrate their noxious 
influence upon very young infants." In the rural districts, 
where the population is sparse, the air is not permanently 
contaminated by the constantly increasing production of these 
noxious elements, and by reason of the more constant agita- 



THE MORTALITY OF YOUNG CHILDREN. 99 

tion of the air, and freer ventilation, there is less clanger of 
infection, even though there may be present local unhygienic 
conditions. 

POVERTY AND IGNORANCE. 
" Illiteracy and foreign born nationality," says Curtis, " go 
hand in hand as causes of infantile diarrhceal diseases." For 
the reason, most apparently, that it is the combination of 
ignorance and poverty. These misfortunes underlie a great 
variety of unsanitary conditions. Poverty deprives the in- 
fant of proper care and needful sustenance, and imposes 
hardships and cruelties which its tender age and feeble vitality 
cannot bear. Ignorance expresses itself in wanton neglect and 
wicked inattention to the simplest and most necessary duties 
of the nursery ; in very many grave errors of omission and 
commission; and in lack of consciousness of parental re- 
sponsibility for the welfare of defenseless infants. All the 
vices and circumstances of life, so common in large cities, 
which impose hardship and privation upon nursing mothers 
and child-bearing women are so many indirect agencies con- 
ducive to disease among infants. 

ALIMENTATION. 

Notwithstanding the detrimental influences of the meteoro- 
logical and atmospheric conditions, a large number of those 
most exposed to these coincident and predisposing agencies 
escape, and very many succumb to the summer diarrhoeas 
who are free from the deleterious influence of foul and stag- 
nant air, unsuitable dwellings, congregation of persons, priva- 
tion, and uncleanliness. With all the care and vigilance of 
the health department, and the lavish expenditure of the 
accumulated wealth of the millionaire, they cannot be shut 
out of the nurseries of populous cities, however cleanly, com- 
fortable, and luxurious the apartments may be. These re- 
sults may, in some measure at least, find their explanation in 
the intimate and constant relationship between these diseases 
and the physiological and anatomical characteristics of in- 
fancy. 



100 THE MORTALITY OF YOUNG CHILDREN. 

The infantile maladies which furnish the largest quota of 
deaths during the heated summer season are the disorders of 
the digestive l and nervous systems, which hold, the one with 
the other, intimate physiological and pathological relations. 
The frequency of bowel affections, bearing, apparently, a di- 
rect relation to a like frequency of the disorders of the nerv- 
ous system, and their rapid diminution, corresponding with 
a like rapid diminution of nervous disorders, point with un- 
mistakable significance to the important factor age, or the 
physiological and anatomical peculiarities of infancy. If sta- 
tistics prove anything, they establish, at least by inference, 
an intimate physiological connection between the disorders 
of these two systems. They act and react upon each other 
as cause and effect. It is during the nursing and succeed- 
ing age that these two systems exhibit the greatest tend- 
ency to disease. This is the period of most rapid growth of 
the tissues and development of organic life, when the machin- 
ery runs with delicate precision and amazing celerity, assimi- 
lating nutriment for the storehouse of growth. The infant, 
like the swift growing and succulent plant, exhibits in the 
softness and delicacy of its tissues, in the looseness and ten- 
derness of the more stable structures, in its sensitiveness to 
impressions, and in its morbid tendencies the hasty appro- 
priation of the elements of nutrition, and feeble powers of re- 
sistance to the accidents and improprieties of life and to the 
ever-varying changes of the atmosphere. It is during this 
period that the first dentition begins its successive series of 
somewhat singular events, strangely commingling develop- 
mental and morbid phenomena. Then, too, the nervous sys- 
tem manifests, with peculiar force and energy, its perturba- 
ting influences. Feeble development with marked nervous 
irritability invites intestinal disorders. Enervation and nerv- 

1 Jacobi estimates the deaths from diseases of the digestive system dur- 
ing the first year of life at 40.89 per cent, of all the deaths ; and 21.01 
per cent, from respiratory diseases. During the second year 9.06 per cent, 
from diseases of the digestive, and 36.54 per cent, of the respiratory or- 
gans. (Infant Hygiene, Hygiene and Public Health, vol. i., p. 89.) 



THE MORTALITY OF YOUNG CHILDREN. 101 

ous prostration, so frequently the result of continuous expos- 
ure to a high temperature, find their sequences in digestive 
and nervous troubles. Kesidence in the city is a prolific cause 
of nervous as well as of intestinal disorders, attributable as 
much, perhaps, to the constantly recurring scenes of excite- 
ment and the demands of society as to filthy streets, foul ex- 
halations, and a densely populated area. How marked the 
contrast ! In the sparsely populated and elevated regions 
these disorders are rare visitors to the family nurseries, yet 
growth and development go on. The sedation of the pure 
and invigorating country air, of the quiet life of the farming 
regions, is the great preventive of the nervous, as it is the 
great curative of the digestive, diseases of infancy. 

The digestive diseases of infancy include a great variety of 
derangements of digestion and nutrition, resulting from an 
inadequate and unsuitable diet. Professor Parrot attempts 
to reduce the incoherent assortment of morbid entities, under 
which the manifold disturbances and alterations are registered, 
to a single nosological conception, for which he proposes the 
name of athrepsia, signifying denutrition. This he claims 
is always the same disease, having for its distinguishing feat- 
ure progressive wasting of the entire organism, and is always 
characterized by the initial symptom of diarrhoea. This di- 
arrhoea may be the beginning and the end, or may be suc- 
ceeded by various organic disturbances, with resulting mani- 
festations and complications. 

By this broad generalization a great variety of nosological 
terms may be dismissed from the nomenclature of infantile 
diseases, and a closer connection of a common cause with rec- 
ognized results be thereby established. Many terms, now in 
common use to indicate the cause of death, express the special 
manifestation, organic disturbance, or resulting complication, 
of a common cause. This common cause is denutrition, re- 
sulting from inadequate or unsuitable diet. From the stand- 
point of a common setiology the term athrepsia would compre- 
hend cholera infantum, entero-colitis, inflammatory and non- 
inflammatory diarrhoeas, rickets, innutrition, and mal-nutri 



102 THE MORTALITY OF YOUNG CHILDREN. 

tion ; many of the fatal cases of thrush and trismus nascen- 
tium ; many cases of erythema, inflammations of the skin, 
mucous membranes and internal ear, and of coma and convul- 
sions ; together with cases of debility, premature birth, im- 
perfect development, meningitis, hydrocephalus, paralysis, 
scrofula, and consumption, terms not infrequently employed 
either to indicate the final condition of the patient, or to cover 
an indefinite diagnosis. 

Such a classification would always set forth the primary 
cause, to which should be added the term most appropriate 
to indicate the special manifestation or organic disturbance. 
Then the relation of cause and effect could be correctly ascer- 
tained, and registrars of vital statistics could eliminate much 
useless verbiage, and many vague terms, which mislead the 
public and deceive themselves. The relation of many infan- 
tile maladies to alimentation would be definitely defined. 
Preventive medicine would occupy a wider field of operation, 
thereby lessening suffering and mortality. The natural his- 
tory of these affections could be more thoroughly studied, and 
the responsibility of parents would be more prominently set 
forth. 1 

The probability of life increases with the addition of every 
day to infantile life. More infants die during the first than 
during the second day ; more during the first than during the 
second month ; and more during the first year than during 
any subsequent year of life. 2 

The lessening morbility and mortality of the advancing life 
of the newly born establishes the important fact, that to di- 
minish this early mortality the preventive measures must 
begin with birth. 

The foregoing presentation of the various causes of this ex- 

1 The reader will find a liberal synopsis of the views of Professor Par- 
rot, by Dr. Curtis, in the contribution of the latter to Buck's Hygiene and 
Public Health, vol. ii., p. 281. See, also, Amer. Jour. Med. Sci., vol. xxii., 
1876, p. 268. 

2 "More than one half (Jacobi) of those dead before the end of the 
first twelve months perish in the first two months." And more than one 



THE MORTALITY OF YOUNG CHILDREN. 



103 



cessive mortality predicates the no less important conclusion, 
that this mortality results, for the most part, from preventable 
maladies. It is still further shown by observation, and proven 
by statistics, that the disorders of alimentation contribute the 
largest quota to this death-rate. It must then follow that the 
sanitarium, to execute the purpose and fulfil the requirements 
of the bequest, must admit and provide for the proper care and 
management of infants from birth. 

Conceding, then, the reception and protection of nurslings 
as the primary and paramount duty of the institution, and 
proper alimentation as the most important and essential means 
of preventing the great mortality, how best can these objects 
be attained ? 

Milk is the natural aliment of all young animals, and nurs- 
ing at the breast of the mother is the preferable method of 
supplying it to the young. The sooner after the termination 
of labor and the completion of the requisite attention to both 
mother and child the latter is put to the breast, the less will 

half of those dying under five years of age, die during the first year of 
life. 

The following table, constructed by Dr. William L. Richardson from 
data relating to the city of Boston in the year 1875, shows the mortality 
from all causes, among infants and children, during the first months and 
years of life. 

TABLE XIV. A Table of Ages at which the Deaths of those of Five Years of 
Age and under occurred. 

[Paper on Infant Mortality, Report of Boston Board of Health, 1876, page 53.] 



One month and under 

One to two months and under . . 
Two to three months and under . 
Three to four months and under . 
Four to five months and under. . 
Five to six months and under . . 
Six to seven months and under . 
Seven to eight months and under 
Eight to twelvemonths and under 

One year to two years 

Two years to three years .... 
Three years to four years. . . . 
Four years to five years .... 
Five years and under 



No. of living 
Children. 



799 

783 
886 
760 
712 



753 
7,657 
8,4^8 
7.626 
6.941 
6.885 
43,936 



No. of 
Deaths. 



633 
273 
192 
150 
163 
154 
143 
129 
514 
835 
429 
330 
222 
4,167 



Death-rate per 
1,000. 



792.24 

346.69 

216.70 

19.7.36 

228.93 

175.79 

188.94 

171.31 

67.12 

98.25 

56.25 

47-54 

32 22 

94.84 



104 THE MORTALITY OF YOUNG CHILDREN. 

be the loss in weight 2 and muscular vigor of the infant. Im- 
mediate nursing saves and prolongs many lives. Especially 
is this true in regard to the small and feeble infant whose 
ebbing life demands immediate sustenance. Even at this early 
period nature usually provides an imperfect milk in the form 
of colostrum, which is the food best adapted to the beginning 
of the new life. Maternal lactation furnishes fewer victims 
than either wet-nursing or artificial feeding, yet the death-rate 
of mother-nursed babies is far too high. The causes of this 
mortality are, to a limited extent, attributable to the consti- 
tutional vices and physical defects of the mother, but for the 
most part to the condition of life, neglect, over-work, igno- 
rance, destitution, and bad domiciliary surroundings. 

The vices of constitution are comparatively few, and refer 
especially to rheumatic diathesis, syphilitic contamination, 
strumous and tuberculous tendencies, and general anasmia and 
feebleness. 2 These obstacles to lactation, if not entirely re- 
movable, may be greatly modified by prophylactic medication 
and management, but such treatment should precede the 
birth of the child. Syphilis of the mother should not, how- 
ever, always prohibit the nursing of the infant, for it is more 
than probable that both mother and child will be affected 
alike, and specific medication of the mother may accomplish 
the cure of both. The milk of a rheumatic mother will prob- 
ably contain an excess of lactic acid, which will surely induce 
indigestion in the nursling. This may be corrected by ap- 
propriate alkaline medication. Those mothers who may be 
the victims of scrofulous or tuberculous affections cannot 
either properly or safely discharge the duty of suckling. Not 
only may the milk be contaminated and deficient in the nec- 
essary nutritive constituents, but, as a rule, the drain is too 

1 Haake estimates the average loss in the first twenty-four hours at four 
ounces ; Winckel between three and four and one fourth ounces. Boys lose 
less than girls; the larger less than the smaller. The first-born more than 
those born afterwards. 

2 According to the tables of Merei and Whitehead, 46.6 per cent, of the 
mothers in feeble health supply an insufficient amount of breast-milk. 



THE MORTALITY OF YOUNG CHILDREN. 105 

much for her enfeebled constitution. Such a woman may, 
says Jacobi, " raise at her breast sickly, bloated, rachitic chil- 
dren, until at last one is born which she is quite unable to 
nurse, and then for the first time appears in the family a 
noisy, ruddy, muscular baby." It not unfrequently occurs 
that women far advanced in tuberculous disease become preg- 
nant, and complete the period of gestation without any ap- 
parent detriment, sometimes, indeed, with seeming improve- 
ment in general health, but from the moment of birth and 
the beginning of lactation decline rapidly to the fatal end. 
If such women, or even those with hereditary tendencies or 
pronounced tuberculous diathesis, will marry, provision should 
be made to protect their offspring from the transmitted dis- 
ease, so far as it can be accomplished, by a careful and suit- 
able diet, free from such contamination. 

There is another class of mothers who are free from any 
transmissible disease, but whose anaemic and feeble condition 
renders them incompetent fully to discharge the duties of the 
nurse. Their blood is so impoverished that their milk is in- 
adequate in quantity and quality. Improved hygiene, proper 
diet, and necessary medical treatment will restore many to 
the full enjoyment of robust health, and fit them for the 
highest duty of mothers. During the interval it will be nec- 
essary either to supplement maternal lactation, or to substitute 
for it some more suitable aliment. In all such cases, as in 
those child-bearing women who may be strumous or tubercu- 
lous, the new-born baby will probably be feeble and of low 
vitality, rendering resort to artificial alimentation imperative 
from birth. 

Defective lactation from physical causes is not an uncom- 
mon occurrence. Fortunately, a majority of women are capa- 
ble of performing their duty as mothers. They are usually 
healthy women, in good fleshy condition, with large breasts 
mainly composed of glandular structure, and not mere accu- 
mulations of fat. The surfaces of the mammse are well 
marked with veins, the nipples are properly shaped and pro- 
truding, and each is surrounded by a well-developed colored 



106 THE MORTALITY OF YOUNG CHILDREN. 

circle. The secretion of milk is abundant and rich. There are, 
however, many who from various defects of organization are 
not good nurses. Some are weak and sickly, with large and 
flabby breasts, which furnish milk in excess, but watery in 
character, and their children are pallid, and sicken easily. 
Others supply milk in sufficient quantity, but at the expense 
of their own weight and strength ; soon the exhaustion and 
waste become so great that the secretion of milk ceases, and 
compulsory weaning results. A third class, mostly weak and 
impressible women, suffer from incontinence of milk, which is 
greatly and suddenly increased by emotion, and during the 
act of suckling the watery fluid pours so abundantly into the 
mouth of the infant that it cannot be swallowed fast enough, 
and is wasted. 

The causes of these disorders of the milk-flow are obscure. 
Routh ascribes them to peculiarities of temperament, profuse 
menstrual discharges, mammary irritation during catamenial 
periods, suppression of habitual excessive urinary and cutane- 
ous excretions, uterine and ovarian disorders, over-suckling, 
and excessive development of the glandular structure of the 
breast. The medical treatment of these somewhat intracta- 
ble affections varies with the nature of the cause, but all may 
be improved by a suitable regimen and good h} 7 giene. 

Physical defects are, however, more frequently exhibited in 
the inferior quality and scantiness than in the manner of the 
flow. Advanced or too early age at first birth, omission of 
nursing previous infants, insufficient lactation of present chil- 
dren, unusual fright, mental disturbances, diseases of the sex- 
ual organs, malformation, partial or complete absence or 
waste of the secretory glands, excessive deposition of fat in or 
about the mammae, or a tendency thereto, may lessen the food 
supply below the standard requisite for infantile health and 
the maintenance of growth. Routh estimates the number of 
mothers suffering from these disabilities at thirty per cent, of 
all the cases of defective lactation. Some of these, as the too 
early and too late marriages, defects of formation, and per- 
haps some of the mental disorders, are beyond the reach of 



THE MORTALITY OF YOUNG CHILDREN. 107 

science or art ; nevertheless the influence of good example and 
proper training will go far towards obviating the sufferings of 
the infants of such mothers. 

Scantiness and inferior quality of milk are not exclusively- 
confined to those who may be incapacitated by such obvious 
hindrances to lactation as those previously enumerated. 
There are not a few mothers in whom the milk-producing 
function is at fault. Donne 1 has shown that the character 
and quantity of the secretion of the mammary gland at a more 
or less advanced period of pregnancy furnishes evidence of 
the quality of the milk after delivery. There is prepared in 
the gland during gestation a " viscous yellowish matter," — 
an imperfect milk which varies in different women. In those 
in whom it is so scanty that not more than a drop can be ob- 
tained by the most careful pressure, the quantity and quality 
of the milk will be insufficient for the nourishment of the 
child. Another class supply abundant colostrum, " but thin, 
watery, flowing easily, resembling gum water," and exhibit- 
ing under the microscope a " few small and illy-formed milk 
globules." Such mothers furnish milk in sufficient quantity, 
but containing little nutriment. When the secretion of this 
imperfect milk is abundant, thick, and yellowish, the supply 
of milk will be ample and rich in the essential elements of 
nutrition. Such functional defects are dissociated from the 
ordinary ailments of nursing women and the causes of defec- 
tive lactation, and consequently escape recognition until the 
life of the nursling is in jeopardy. Supplemental alimentation 
in such cases, may be the only method of rescuing the infant 
from death by starvation, but unfortunately the innutrition 
dates from birth, without the true cause being discovered, 
and treatment is therefore often misapplied to the child, 
whilst the starving goes on, with perhaps daily abatement of 
food supply, either because the milk producing capacity of 
the mother diminishes from day to day, or, as more frequently 
occurs, improper and unnecessary medication of the infant 
adds its deleterious influence to the already enfeebled diges- 
tion. 

1 Mothers and Infants, page 30. 



108 THE MORTALITY OF YOUNG CHILDREN. 

Milk consists of a colorless fluid, oil globules, milk globules, 
granulated corpuscles, a volatile principle not yet isolated, 
and extractive matters of which nothing is known. Devergie 
concluded from his observations that milk might be divided 
into three varieties : (1) milk with large globules ; (2) milk 
with small globules ; and (3) milk with medium-sized glob- 
ules. The more numerous the large globules the richer the 
milk. " Out of 100 (Routh) women, seventeen had the first 
variety, and in ten of the seventeen, lactation increased their 
number. Twenty -two had the second variety, and of these sev- 
enteen had the richness of their milk increased by lactation." 

The omission of nursing previous infants and insufficient lac- 
tation of present children are reprehensible practices, inexecus- 
able except for such causes as may physically incapacitate the 
mother for the performance of a duty which is the birth-right 
of her baby. They belong, however, to two entirely different 
classes of women. The vice of omission is usually the wicked 
act of an indolent, luxurious, and licentious woman, whose devo- 
tion to the frivolities of society and the aesthetic attractions of 
life override the instincts as well as the obligations of a mother. 
The second class are mostly mothers without means of sup- 
port, who are compelled to labor for a livelihood, and can 
give the baby the breast only during a hurried visit morn- 
ing and evening. During the interval the infant is often 
insufficiently and improperly fed. Numerous such instances 
have fallen under the observation of the writer, and Bouchut 
calls attention to the fact that, in Paris, non-inflammatory 
diarrhoea is very prevalent among the infants of mothers who, 
" obliged to work in order to sustain their existence, quit 
their infants in the morning, return at several moments of 
the day to give them the breast." Apart from any consider- 
ation of the constituent alterations which may be produced in 
the milk by the mental disquietude growing out of the con- 
viction of moral turpitude or the privations of poverty, the 
" disagreement " of the milk with the baby, so frequently the 
alleged cause of the early weaning generally practised by 
those " at service mothers," finds its explanation in the watery 



THE MORTALITY OF YOUNG CHILDREN. 109 

condition of the milk, which has been shown by M. Peligot 
to be proportionate to the length of time it has been retained 
in the breast. A mother who improperly prolongs the inter- 
val not only punishes the baby with hunger, but compels it 
to take food which her neglect has unfitted for its delicate 
digestion. And if, as sometimes happens, the baby con- 
tinues to fret and cry, its little mouth is again stuffed with 
the nipple, but after a moment's pause the shrieks are more 
frantic than before, and then the other breast is tried, but the 
cries grow worse and worse, and now mother and father, if the 
latter can be aroused from a quiet sleep in some apartment 
far removed from the nursery, join in the frantic jubilee of 
walking the floor to and fro, jostling the baby up and down 
in their arms, and humming in the doleful tone of unutterable 
despair " by-zee by-zee baby" until all, too exhausted longer to 
continue to outrage nature, fall asleep, and when the morn- 
ing comes the wearied parents wonder why their baby is so 
nervous, either not knowing or affecting not to know that the 
baby's health is being injured and its temper made irritable 
through their neglect, or because they are unwilling to forego 
pleasure inconsistent with the duties of nursing mothers. 
Whether wilful or unavoidable, insufficient lactation is alike 
injurious to the nursling. The former cannot be remedied 
except through the restraints of moral responsibility ; the lat- 
ter demands the assistance of the charitable and the good. 
The sanitarium can, at least during the summer season, offer 
to many deserving but poor mothers shelter and home, and 
instruct them how best to obviate the danger to the baby, 
which such manner of nursing incurs. In some cases a resi- 
dence in the institution, for a shorter or longer time, will con- 
duct the baby through the critical period of its life, and place 
it beyond the impending peril resulting from the poverty of 
its mother. 

Early recurrence of menstruation and pregnancy and exces- 
sive sexual indulgence during the period of lactation seriously 
deteriorate the nutritive qualities of the milk. In a majority 
of women the reproductive function is in abeyance during the 



110 THE MORTALITY OF YOUNG CHILDREN. 

normal period of lactation, which varies in duration from 
birth to the ninth or fifteenth month, but usually should not 
exceed one year. No mother can adequately nourish at the 
same time herself, a foetus, and a child at the breast. In such 
cases three beings suffer more or less, and not seldom the 
unborn is lost either by abortion or other accident, while 
more frequently the infant begins a separate existence with 
vitality insufficient to maintain life beyond a few hours or 
days ; and if, perchance, it should be saved from such im- 
mediate peril, the subsequent life will be, to a more or less 
extent, characterized by feebleness of constitution and di- 
minished resistance to morbific agencies. Many succumb to 
the maladies of early life. Chemical analyses of the milk of 
pregnant women as well as clinical observation of their nurs- 
lings affirm the incompatibility of pregnancy and lactation. 
Professor Davis 1 ascribes the deleterious changes mainly to 
the loss of fat, salts, and casein, and retrogression to the nat- 
ure of colostrum. Milk, says Jacobi, 2 is not the product of 
cell action, but the transformed cells of the gland, and when 
this change is incomplete the secretion is imperfect, resem- 
bling that usually found in the breasts before delivery. When 
then the generative activities are diverted into another chan- 
nel to meet the extraordinary demands of an impregnated 
womb and the development of a new being, it is not strange 
that the process of milk elaboration should be interrupted. 
The earlier during the period of lactation the pregnancy be- 
gins, the more serious the changes produced in the milk, and 
the more detrimental such alteration to the nursling. It so 
happens that the larger number of such recurring pregnancies 
take place about or subsequent to the fifth month of the in- 
fant's life, during the period when the first dentition is run- 
ning its course of nervous disturbances, febrile exacerbations, 
and local irritations, and oftentimes the ailments of the child, 
previously healthy and vigorous, are ascribed to the cutting of 
the teeth, when in fact the cause lies concealed in the cavity 

1 Trans Amer. Med. Ass., 1855, page 53 7. 

2 Infant Hygiene; also Amer. Jour. Obst., vol. x., page 353. 



THE MORTALITY OF YOUNG CHILDREN. Ill 

of the mother's womb. It is fortunate that the age in most 
of the cases is far enough advanced to admit of supplemental 
alimentation, or artificial feeding, with a greatly increased 
probability of life than during the earlier months of infancy. 
The qualitative changes produced in the milk by men- 
struation : are analogous, but less marked than those occa- 
sioned by pregnancy. The proportion of sugar is diminished, 
but the amount of butter is not so much lessened. Perhaps 
the most important changes consist in the altered condition of 
the milk corpuscles, and the increase of the albuminates. 
Menstruation recurs in a majority of women before the ex- 
piration of the time of nursing, and when delayed to the 
ninth or tenth month, the infant does not often suffer, because 
at that age it is usually capable of maintaining an independ- 
ent subsistence. Hence there is very great diversity of 
opinion in regard to the influence upon infantile life of the 
menstrual return during lactation. No one will assert the 
conclusion that every child must be weaned at the moment of 
the reappearance of the menses. The safest guide is the con- 
tinued growth and good health of the nursling. If it loses 
weight, and its health becomes impaired, especially if the 
digestive disorders, however trivial, are consentaneous with 
the menstrual periods, the relation of cause and effect is suffi- 
ciently established. 2 But the season of the year and locality 
of habitation must not be disregarded. Maternal nursing, 
even when the milk is deteriorated, is often preferable to arti- 
ficial feeding. Clinical observation and intelligent experience 
must determine the proper course to pursue, both as regards 
weaning and artificial feeding. Pregnancy produces changes 

1 Davis, Marcliand, Vernois and Becquerel, and Fleischmann. 

2 " Morbid conditions of the mammae are frequently due to diseases of 
the womb ; in some cases it has excited tumors in the mamma? ; in other 
instances it has disordered their secretion, and ultimately proved the 
cause of derangement of the health of the infant. A familiar example of 
this occurs in those mothers who have begun to menstruate before they 
have ceased from suckling : at each return of the catamenia the child 
is in many instances, distinctly disordered in health." (Marshall Hall.) 



112 THE MORTALITY OF YOUNG CHILDREN. 

more uniformly dangerous to the nursling than the return of 
the monthly flow, but it is not always delayed till the latter 
occurrence. Some women will conceive during the continued 
suspension of the catamenia, especially during the later 
months of lactation. Its reappearance is nature's most signifi- 
cant admonition of the coming event, which is the more 
probable the sooner and the more regular the return of the 
periodic " show " after delivery. 1 

Notwithstanding the diversity of opinion in regard to any 
constant deleterious influence of menstruation upon the lacteal 
secretion and consequent effect upon the nursling, individual 
experience is of great value in determining the causal relation 
of such qualitative deterioration to special infantile maladies. 
This is most conclusively shown in that nutritional disorder, 
known as the " English disease " or rickets, which so often, 
because of its insidious approach, escapes observation, until it 
is too late to prevent structural alterations and deformities. 
This disorder, at first believed to be confined to the children 
of luxurious and dissipated parents, is now known to be com- 
mon to all classes of society, but is most common among the 
children of the poor, because of the more general prevalence 
among them of the causes which disturb the nutrition and de- 
velopment of early life. It is the result of blood impoverish- 
ment, with consequent imperfect structural evolution, most 
strikingly exhibited in arrest of the process of ossification, 
rendering the bones soft, flexible, easily distorted, and causing 
deformities always interfering, more or less, with a healthy 
and vigorous life, and very often terminating it at an early 
age. Its first symptom is not infrequently habitual consti- 
pation, which the unsuspecting mother ascribes to inherit- 
ance. It may be occasional acid vomiting, or trivial loose- 
ness of the bowels, occurring and recurring without manifest 
cause, is attributed to high temperature, insalubrious habi- 
tation, teething, or some other accessory and equally remote 

1 Of 685 pregnancies recurring during lactation observed by L. Mayer, 
menstruation began after six weeks in 99; after twelve weeks in 46; and 
after four months in 41. 



THE MORTALITY OF YOUNG CHILDREN. 113 

agency, and which yield for the time to treatment, harmless 
in so far as it may calm the current alarm and defer a more 
serious attack, but baneful in that it adds the deception of a 
transient and mistaken cure to the concealment and misun- 
derstanding of cause, and transfers the responsibility for the 
misfortune from the nurse to the infant. During this period 
of misapplied remedies the baby may even increase in weight 
and grow fat, but its flesh is flabby, its blood poor and thin, 
its color white, and its temper uneven if not irritable. The 
further progress and insidious course of the disease will be 
exhibited in the copious sweatings about the head, rolling of 
the head on the pillow, wearing off of the hair from the back 
of the head, inability to hold the head up, beading of the an- 
terior extremities of the ribs, grooving of the ribs near their 
front ends, flattening of the lateral chest walls, chicken-breast- 
like projection forward of the breast bone, enlargement of the 
wrists and ankles, teething delayed beyond the tenth month, 
increase in the " mole " (or opening at the top of the head) 
beyond the sixth month, and closure delayed beyond the fif- 
teenth or sixteenth month, delayed walking, bending of the 
legs below the knees, and other successive and more disastrous 
deformities of the bony frame, which may so compress, distort, 
and displace the internal organs that not a single vital func- 
tion can be performed in a proper manner, and life will be- 
come the profitless pursuit of a disqualified existence. A 
number of those who may survive, with apparent restored 
health, will succumb finally to wasting phthisical affections, 
and if, perchance, offspring should be born unto them, such 
children may inherit rickets. 

Sir William Jenner was the first to suggest that anaemia 
and general feebleness of the mother were important factors 
determining the development of rickets in the nursling. Ca- 
zeaux advanced a step farther and suggested a " relation of 
causality between rickets of the infant and the frequent oc- 
currence of the menses during the greater part of lactation ; " 
but Tilbury Fox 1 was the first to assert and prove the direct 
1 Obstetrical Transactions, London, vol. iv., p. 260. 



114 THE MORTALITY OF YOUNG CHILDREN. 

relation of cause and effect. From numerous observations 
carefully recorded he deduced the important conclusion that 
when rickets attacks a i4 child entirely dependent upon the 
mother's milk, the mother will be found to have menstruated 
during lactation regularly for several months, and the degree 
of rickets will be in direct ratio to the frequency, duration, 
and amount of menstrual flow." The experience and obser- 
vation of the writer fully corroborates the testimony of Fox. 
The clinical records of the Children's Hospital of Washington 
will not only supply numerous illustrations of this relation of 
cause and effect, but will also go far towards establishing a 
connection between rickets and final strumous and consump- 
tive maladies. Tabes mesenterica, or " consumption of the 
bowels," is the usual form of the latter, and a common termi- 
nation of rickets. 

Rickets has been cited as an example of those nutritional 
disorders, classed as distinct morbid entities, which, except the 
few isolated hereditary instances, is always traceable to the 
inadequate and unsuitable alimentation of the infant, and the 
proper treatment of which is so constantly delayed until the 
structural alterations have so far advanced that restoration is 
impossible. Its early recognition and the removal of the cause 
would not only save very many lives, but would greatly 
diminish the number of chicken-breasted, flat-sided, hump- 
backed, knocked-kneed, pigeon-toed, and otherwise deformed 
men and women, who are so much more numerous among those 
born and reared in the cities than among an equal number of 
people who were born and have passed their childhood in the 
country. 

The influence of sexual excess in deteriorating the lacteal 
secretion has not been definitely determined. The delicacy of 
the subject and the innate modesty of women interdict any 
positive investigation. The lust of the grosser sex will in- 
variably hide behind an equivocation or a falsehood, and hu- 
man judgment will always differ as to what constitutes an ex- 
cess. It is only by parity of reasoning that any conclusion 
can be reached. Conjugal excess is perhaps as common, and, 



THE MORTALITY OF YOUNG CHILDREN. 115 

certainly, no less a vice than masturbation. Woman is the 
highest type of the breeding female, yet she is the only one 
not exempted from the approach of the male by a natural 
periodic interval of sestus. Surely, if natural functions are to 
be studied by the examples which nature furnishes, it ought 
not to be difficult to determine, in the human female, the re- 
lation of the normal gratification of the generative desire to 
its abuse by excessive indulgence. It is a law of the physical 
economy that excessive indulgence of any animal passion, or 
the over-work of any function or organ, is detrimental to the 
whole organism. The obvious effects of marital excess are not 
infrequently shown in the pallid, wan, and careworn physiog- 
nomy ; in the nervous irregularities and perturbations which 
make life miserable : in the various digestive disturbances 
which so seriously interfere with nutrition and blood making ; 
and in the emotional exultations, as well as mental obliquities, 
which so often mar the symmetry of a happy wedded life. 
Excess begets excess, and premature decay, old age, and 
death result. Any excess which will produce such disastrous 
consequences must seriously disturb the mammary secretion. 
The unwholesome and sometimes pernicious changes produced 
in the mother's milk by sudden bursts of passion, by a nervous 
temperament, emotion, mental anxiety, and sorrow, by men- 
struation, pregnancy, and excessive sexual indulgence, are too 
well established by clinical observation, if not by chemical 
analysis, to be considered mere coincidences unworthy of the 
attention and careful scrutiny of the scientific physician. 

Mental anxiety and sorrow are the most powerful of all 
causes (Routh) in producing defective lactation. A sudden 
burst of passion, fright, or violent agitation, will often produce 
in the baby violent diarrhoea, vomiting, convulsions, and some- 
times death. " No secretion," says Carpenter, " so evidently 
exhibits the influence of depressing passions as that of the 
marams." " A fretful temper," says Cooper, "lessens the 
quantity of milk, makes it thin and serous, and causes it to 
disturb the child's bowels, producing intestinal fever and much 
griping. Fits of anger produce a very irritating milk, fol- 



116 THE MORTALITY OF YOUNG CHILDREN. 

lowed by griping in the infant, with green stools. Anxiety 
of mind diminishes its quantity, as in the case of a mother 
anxious for a sick child. Her milk, under these circumstances, 
will often produce green spotty motions with tormina. Ter- 
ror is more powerful." " Those passions which are generally 
sources of pleasure in health, when carried to excess, alter and 
even check the secretion of milk. The case is related of a 
mother who in an effort to protect her husband, became vio- 
lently excited, and after becoming quiet, gave the breast to 
the child, which in a few moments ceased nursing, became 
restless, panted, and died* upon its mother's bosom. Mr. 
Wardrop records two similar instances : in one the child died 
in convulsions after nursing its mother, who had been in a 
violent passion ; in the other, the fatal convulsions followed 
taking the breast of a nurse who had been severely repri- 
manded. Burdach records three cases ; in one the child was 
seized with convulsions, immediately after its mother had met 
with some distressing occurrence. Carpenter records two 
cases ; in one the child nursed its mother, who was fretting 
because of absence from friends ; in the other the mother was 
in great grief because of having lost a child in convulsions. 
Simon 1 examined the milk of a recently delivered woman, 
whose child was seized with vomiting, diarrhoea, and convul- 
sions, after nursing during a fit of passion. The milk was 
alkaline, and when boiled had a strong animal odor. After 
twelve hours it developed a large quantity of sulphuretted 
hydrogen ; and yet the casein, sugar, and butter had not un- 
dergone any change in quantity or quality. De}^eux 2 found 
that the milk of a woman who was liable to frequent nervous 
attacks became, simultaneously with such attacks, transpar- 
ent and viscid, like albumen, and did not resume its normal 
condition till some time afterwards. The analysis of the 
milk of a woman in a state of nervous excitement showed 
the diminution of the solid constituents to ninety-one parts in 
one thousand ; only five parts of butter. 

Many of the causes, previously mentioned, which interfere 
1 Routh. 2 Routh. 



THE MORTALITY OF YOUNG CHILDREN. 117 

with the suitable alimentation of young infants are unremov- 
able, because they originate in incurable defects of the female 
organism ; but there is another class of causes equally disas- 
trous to nursing babies, which are avoidable and, in some 
respects, inexcusable. The most common of this class relates 
to the diet of the mother. It is undoubtedly true that among 
the unfortunate class the food supply is frequently insufficient 
as well as unfit. Decaisne has shown 1 that insufficient food 
may occasion very serious and varied disturbances in the 
quality of 'the milk. In his report to the Academie cles 
Sciences of the results of his observations of women who 
nursed their infants during the siege of Paris, he deduced the 
conclusions that some women may, upon insufficient diet, pro- 
duce abundant and rich milk, and their children will thrive, 
while they themselves will emaciate ; another class will pro- 
duce but little milk, and that very poor, and their children 
will suffer for want of nutriment, and sicken with choleraic 
diarrhoea, and a third class will produce scarcely any, and 
their children will die. Insufficient food is a frequent cause 
of chronic infantile diarrhoea, but it much more frequently re- 
sults from the improper than from the inadequate diet of the 
mother. A meagre diet affects the quantity of butter and 
casein ; a bad diet imparts deleterious qualities. 

That the quantity and quality of milk are dependent upon 
the food and the vigor and healthfulness of the digestion is 
beyond dispute, but so variable is the function of lacteal secre- 
tion in women that no general law can be asserted. Every 
one is familiar with the facts that garlic, the onion, cabbage, 
turnip, and even green clover impart a distinctive aroma to the 
milk of the cow. Lettuce opium, or lactucarium, has been de- 
tected in the milk of animals. Coloring materials pervade all 
the tissues and secretions. Mosler has witnessed the yellow 
coloration of milk from the eating of saffron, rhubarb, and 
cowslips ; and red from cochineal, madder, and rhubarb. 
Schauenstein and Spath have observed it colored blue by my- 
osotis palustric, bistort root, bugloss, and horse-tail. Ethereal 
1 London Lancet, September, 1872. 



118 THE MORTALITY OF YOUNG CHILDREN. 

oils are sometimes eliminated through the mammary secre- 
tion, but their presence has not been detected by any chemi- 
cal tests. Poisons have undoubtedly been conveyed through 
the milk. An epidemic of severe sickness occurred in the 
neighborhood of Rome, Italy, from the use of the milk of 
goats pastured where a variety of poisonous plants grew. 
The active principle of some of these plants was detected in 
the masses vomited by the patients. Poisoning of infants by 
alcohol, opium, and morphia has no doubt frequently occurred, 
yet they cannot be positively detected in the milk. The in- 
vestigations in regard to inorganic substances has been very 
much more satisfactory. Bismuth, iodide of potassium, 
arsenic, lead, oxide of zinc, antimony, mercury, the carbonate 
and bicarbonate of potassium, and the sulphates of sodium 
and magnesium have been detected in milk. It is true the 
results of the experiments have varied, but it seems generally 
admitted that the younger the milk the greater the proba- 
bility of the elimination of these substances, when taken, 
through the mammary secretion, and this conclusion is in en- 
tire accord with the clinical observation that the younger the 
infant the more certainly it may be affected by drugs admin-- 
istered to the mother. It has grown to be a proverb among 
nurses that the routine dose of castor-oil on the third day 
after confinement gripes the baby. In explanation of the 
constantly varying results, both experimental and clinical, 
Jacobi says, milk which contains admixtures of transuded 
serum is apt to become impregnated with foreign materials 
circulating in the blood, and milk secreted from an insufficient 
mamma, by a woman not in full health, by an old or very 
young woman, by an anaemic, convalescent, or neurotic woman, 
and by one soon after delivery, is more like a transudation 
than a glandular secretion. 

The foregoing facts and considerations establish the conclu- 
sion that certain mineral and poisonous substances, reaching 
the blood through the digestive organs, may be eliminated 
through the milk, and be thus conveyed to the nursling, and 
that the probability of such a result is greater the sooner after 



THE MORTALITY OF YOUNG CHILDREN. 119 

birth such material may be ingested, and is greatly increased 
by certain conditions of the mother. That the same rule 
holds good in regard to articles of diet is a matter of daily ob- 
servation. This is conclusively shown by the observations 
and experiments of competent investigators on the modifica- 
tions produced in the milk of animals by diet. Mayer of Ber- 
lin (as stated by Routh) examined the milk from a number 
of cows, with the following results : — 

" Of cows fed with brewers' lees, red potatoes, rye bran, 
and wild hay, in five instances the milk was slightly acid ; in 
one very much so. 

" Of forty cows fed with potato mash, barle}^ husk, and 
clover and barley straw, in ten which were examined the 
milk was acid ; in three very acid. From among fifty cows 
fed on potato husks, barley husks, and wild hay, the milk of 
five was examined and found acid. 

" From forty-two cows fed on potato mash, husks, wild ha}% 
and rye-straw, the milk of twelve selected was acid. 

" The milk of six cows fed on beet root, red potatoes, bran 
mash, and hay, was greatly acid." Playfair relates (Routh) an 
example of a cow fed on nitrogenous food, with marked increase 
in the quantity of nitrogenous matter, casein, and butter. Par- 
mentier and Deyeux found the milk of cows fed on the leaves 
and stalks of maize sweeter and more abundant than when fed 
on ordinary fodder ; and that from cows fed on common grass 
and potatoes was watery and insipid. When fed on cabbage 
the taste was disagreeable. Hermanstadt says, fresh aliments 
produce a larger quantity of sugar in the milk than dry food. 
Curwin found coleseed more productive of milk, when fed to 
cows, than either Swedish cabbage or Kohl-rabbi. Anderson 
asserts that cows fed upon grass in addition to trefoil yield 
butter superior to that when fed upon the latter only. Seh- 
mann says, the milk of bitches " fed on a vegetable diet is 
richer in butter and sugar, while the solid constituents are 
augmented when a sufficient quantity of mixed food is given." 
Peligot found (Smith) the amount of casein increased in the 
milk of an ass when fed upon beet root, and the butter in- 



120 THE MORTALITY OF YOUNG CHILDREN. 

creased when the food consisted of oats and lucerne. Bous- 
singault says, the milk of the cow is richest in casein when fed 
upon potatoes. Reiset and Playfair differ in regard to the 
effect of stall-feeding of cows on the quantity of fat in the 
milk, the former asserting that the quantity is greater when 
they are grazed. A commission (Routh) of the medical fac- 
ulty of Paris, in 1771, reported " the potato to be particularly 
useful in increasing the quality and the flow of the milk ; also 
when eaten by the mothers of thin, weakly children, a rapid 
improvement of the latter followed." The milk of stall-fed 
cows, unless they are fed exclusively on grass, is always acid, 
especially so when (Mayer) fed on potato mash and refuse, 
cabbage or turnips. The worst is that supplied by cows fed 
on potato refuse from brandy distilleries ; and the best is that 
from cows fed on hay and grass in stalls. These observations 
show that the milk of animals varies according to the kind 
of food, especially in regard to its alkalinity. The milk of 
women should always be alkaline, but it is well known that 
indigestible and acescent food make the milk disagree with 
the baby, because of its influence on the alkalinity of the 
milk. The prevalence of this element of causation of infan- 
tile bowel diseases cannot be ascertained, and its importance, 
in view of its easy prevention, should not be underestimated. 
The diet of poor mothers residing in cities is a matter of 
necessity and not one of taste or indulgence. They seek to 
satisfy hunger, rather than to supply the wants of the organ- 
ism. They eat because nature demands food, and necessarily 
use that which they have, or can get. Their necessitous con- 
dition will neither admit of over indulgence nor the gratifica- 
tion of tastes or fancies. Many will even deny themselves 
the allotted part of the family dietary 1 because the other 

1 " Simon made the analysis of the milk of a poor woman. She was 
suddenly, during the period of lactation, deprived of the means of support, 
so that her food was insufficient in quantity and of poor quality. The 
amount of her milk was not diminished by privation, but the solid constit- 
uents were reduced to 86 in 1000 parts. After this, for a time, her diet 
was nutritious and abundant, the quantity of milk increased, and the solid 



THE MORTAl,i'iY OF YOUNG CHILDREN. 121 

members are inadequately supplied, or abstain from certain 
articles because of the disagreement of the milk with the 
baby, or confine themselves to innutritious foods because they 
" go to milk." Such mothers are objects of pity and commis- 
eration, and the suffering and starving babies appeal to the 
noblest impulses of a charitable community for succor. Not 
so, however, with those mothers whose wicked indulgences of 
appetite are persistently adhered to in the face of the fact 
that the little one is being cruelly punished with gripes 
and colic. The M nine days " and " three months' colic " of 
nurslings more often find their cause in faulty alimentation 
than in physical defects or constitutional peculiarities. The 
continuance of the undiscovered cause undoubtedly impairs 
the feeble digestion, and what at first may be simply nature's 
remonstrance against the dietary outrages, eventually becomes 
a superadded ailment, which augments the perils of its de- 
pendent condition. There is no universal law governing the 
diet of nursing mothers. The health and growth of the 
child, living exclusively upon its mother's milk, are the most 
important evidences of the adequacy of the sustenance, and 
the special morbid manifestations constitute the only indica- 
tions of its insufficiency. The results are usually obvious 
enough, but the discovery of the exact cause, especially when 
it relates to the diet of the mother, is not always an easy task, 
because the unsuitable quality of the milk may be due to 
some unknown and undiscoverable physical defect, either ap- 
pertaining to the secretory function of the mammary gland, 
or to some one of the complex functions of assimilation and 
nutrition, or may lie concealed in some vicious habit of the 
constitution or disposition. 

The quality of the milk is influenced by the condition of 
the weather and by the season. The adult organism is not 

constituents amounted to 119 parts in 1000. Her diet -was again reduced, 
with a reduction of the solid element to 98 in 1000, and, at a later period, 
the diet was again nutritious, with an increase of the solid elements to 
126. The chief variation in the milk of this woman was in the amount of 
butter." Smith, Diseases of Children, page 58. 



122 THE MORTALITY OF YOUNG CHILDREN. 

exempt from the effects of the variations of temperature. 
Poor mothers can neither protect themselves from cold, nor 
avoid the sweltering heat of the summer exacerbations ; and 
it is not improbable that the qualitative alterations of the 
glandular secretion caused by excessive and continuous high 
temperature is a constant agency, cooperating with the same 
detrimental influences upon the infantile organism, in produ- 
cing disturbances of digestion. But the quality of the milk is 
more constantly and effectively influenced through the changed 
conditions of life incident to the seasons. In the summer sea- 
son the pollution and stagnation of the heated atmosphere, 
the general unsanitary condition of cities and habitations, the 
character of the food, and more frequent indiscretions of diet 
and indulgences of fancied cravings for beverages must, in 
very many cases, injuriously influence the quality and quan- 
tity of the lacteal secretion. It may be a coincidence, yet it 
is nevertheless true, that the larger percentage of intestinal 
diseases and deaths occurs among nurslings during the season 
of the year when vegetables and fruits are most abundant 
and deterioration most rapid ; that they are proportionately 
far more frequent in communities of consumers, who can only 
obtain supplies by purchase ; and that they are largest among 
the infants of the poor and squalid, the class necessarily the 
most indiscreet consumers of cheap and deteriorated fruits 
and vegetables. As yet, the food supply of poor nursing 
women is an unascertained factor in the causation of infantile 
diseases. The few known facts are corroborated by clinical 
experience and observation. Reasoning by induction the con- 
clusion is inevitable that it is a more common and potential 
element than has been generally believed. It will come 
within the province of the sanitarium to thoroughly investi- 
gate this question, for in its domiciliary department it can as 
definitely regulate the diet of the mother as it can that of the 
infant, and can ascertain as well the qualitative and quantita- 
tive changes produced in the milk by different foods as it can 
the effects of such alterations upon the health and nutrition 
of the child. Should it be, through the operations of this in- 



THE MORTALITY OF YOUNG CHILDREN. 123 

stitution, affirmatively settled, new and wider opportunities 
will be opened to sanitary science ; and health officers will at 
least give a portion of their time to the inspection of foods, 
and not devote it wholly to the search for the fetid and subtle 
emanations which hvgienists have striven so long to define 
and circumscribe. One fact should long since have demon- 
strated itself to every intelligent person, that the hauling 
through the streets and offering for sale of the refuse fruits 
and vegetables from the cit^^ markets, rotten and rotting 
under a blazing sun, — a perambulating auction of brawling 
attendants, starving beasts, stale and rotten fruits and vegeta- 
bles, and noxious effluvia, — is a nuisance as discreditable to 
the government of a civilized community as it is detrimental 
to the poor but unsuspecting patrons. 

The secretion of the mammary gland is also influenced by 
the habits and vices of women. 1 Alcoholism and opium eat- 
ing are familiar vices ; over-crowding and over-work are more 
prevalent but not less detrimental. Sedentary habits, per- 
sonal uncleanliness, and personal neglect and abuses, not in- 
frequently deteriorate the milk. Dyspepsia, chronic dis- 
charges, and habitual constipation are quite common causes 
of indigestion among nursing babies. Chronic constipation 
seems to be one of the habits of the female constitution fre- 
quently transmitted to the offspring, for the coincident rela- 
tion of cause and effect is so constantly repeating itself, that 
the " sucking of costiveness from its mother and grandmother 
before," has become a proverb among nurses and grandmoth- 
ers. Be that as it may, the fact is that the babies of women 
who habitually neglect the evacuation of their bowels are 

1 "Among the ancients, especially among the Romans, the moral qual- 
ities were considered of more consequence than the physical capacity of a 
nurse; and by them consequences of such moment and extent were at- 
tributed to them as, at the present day, at least, we should not expect to 
realize. The habit of intoxication, to which Nero so immoderately yielded, 
was said to be owing to the influence of a drunken nurse; and the blood- 
thirsty disposition of Caligula was attributed to the nipple being smeared 
with blood, to invite him to take it with more certainty, by his savage foster 
parent." 



124 THE MORTALITY OF YOUNG CHILDREN. 

often victims of constipation, wind colic, and " crying spells," 
satisf actor} 7 evidences usually of an unsuitable diet. Bat, 
then, every such case is not the result either of constitutional 
habit, inheritance, or improper diet. More frequently it is 
the result of the criminal administration of laudanum. This 
drug is as regularly carried by nurses, and some mothers, as 
their scissors or thimble, and is considered much more indis- 
pensable to their comfort. If the child does not go to sleep 
at the exact moment of their convenience, or if it cries at in- 
opportune times, laudanum is given to make " assurance dou- 
ble sure." The dosing of infants with narcotics and alcoholic 
stimulants, when not necessary in the treatment of disease, 
is a more reprehensible practice than amateur doctoring, and 
usually leads to more serious consequences. 

Protracted and irregular lactation are fruitful causes of dis- 
ease among infants. The former is frequently practised to 
prevent pregnancy ; the latter is often caused by the necessi- 
tous condition of the mother, but more frequently it is from 
neglect. In the cases of protracted lactation the child is in- 
adequately fed on a watery fluid drained from the gland after 
its functional activity has ceased, and the condition of the 
mother is such that even if the secretory function remained 
in normal physiological vigor, the blood supply would be 
wholly inadequate. The breasts are flabby, and hang like 
loose, pendulous sacs of ill-used integument. Irregular lacta- 
tion produces scantiness of milk, and unfits even what is se- 
creted for use by rendering it more watery. The first that 
flows from the breast was first secreted and is the poorest ; 
and that which flows last was the last secreted and is richest ; 
the solid constituents being more readily absorbed than the 
fluid. Advanced age, and too early age at first birth, are 
common causes of scantiness of milk ; in the former from ac- 
cumulation of fat, commencing atrophy of the secretory struc- 
ture, and long disuse ; in the latter because of immature de- 
velopment of the glandular structures. 

Over-feeding and over-lactation are also causes of defective 
lactation. The former, says Routh, is the rarest variety and 



THE MORTALITY OF YOUNG CHILDREN. 125 

by far the most remediable. Over-feel mothers become gross, 
plethoric ; their faces become covered with pimples and blotches ; 
their breasts enlarge from accumulation of fat, the veins on 
the surface become less distinct, the secretion of milk grad- 
ually diminishes, and finally ceases altogether. Over-lactation 
may be due to defects of organization or temperament, which 
induce too abundant flow, but more frequently it is the result 
of too constant and too long continued nursing, and is most 
frequent among inexperienced and poor mothers, who are in- 
sufficiently supplied with nutritious food. The symptoms of 
hyperlactation are well marked. Such women have a haggard, 
starved look, are weak and anaemic ; their eyes are sunken, 
with dark lines under them ; they surfer with pains in the 
back, leucorrhoea, breathlessness, and exhaustion. Sight and 
memory are occasionally impaired. Ashwell has witnessed 
cases of epilepsy and insanity caused by over suckling of in- 
fants. Fruitless sucking is not free from danger to the child. 
Billard has shown that it is often a cause of infantile diarrhoea 
and convulsions. 

From the foregoing consideration of the causes of defective 
lactation two conclusions may be deduced : First, that the 
secretion of the mammary gland is an unstable product, vary- 
ing in composition and quantity from a great variety of con- 
ditions ; and, second, that many cases of defective lactation are 
curable, and the mothers, under proper treatment and super- 
vision, may not only be enabled to fulfil their dutijes without 
injury to themselves, but to the great advantage of their chil- 
dren. Many of the causes need further investigation, and the 
sanitarium will offer unusual opportunities for the prosecu- 
tion of experiment and investigation which may result in im- 
portant additions to the methods of treating such cases. 

SUPPLEMENTAL ALIMENTATION. 

For the present the primary object is the prevention of the 
injurious effects of defective lactation upon nursing infants. 
The chief obstacle to the successful management of these cases 
is the difficulty of an early recognition of the precise nature 



126 THE MORTALITY OF YOUNG CHILDREN. 

of the cause. This difficulty in most instances grows out of 
the trivial character of the initial symptoms, and ignorance of 
the fact on the part of the mother, or unwillingness to believe 
that the cause is attributable to any physical defect of her or- 
ganism, or any impropriety in her conduct, or her method and 
manner of nursing. Generally the innocent but ill-used in- 
fant is charged with various disabilities or flagrant exhibitions 
of connate perversities, and dosed with medicines until some 
serious organic change has taken place. 

In all cases of defective lactation the infant must be pro- 
tected : either by weaning and artificial lactation ; by removal 
of the cause of defective lactation ; or by supplementing the 
natural aliment of the child. When the defect is a natural 
scantiness due to advanced age, atrophy, absence, torpor, or 
imperfect development of the glandular structure, or obesity 
of the breast, the giving of additional aliment to the infant 
will, probably, be the only recourse ; but in those cases in 
which the defect is attributable to habit, diet, occupation, want, 
constitutional debility, the improprieties and circumstances 
of life, over-work, and insufficient, irregular, and over-lacta- 
tion, the removal of such cause, not always easily accom- 
plished, will usually restore the mother to the full performance 
of her duty as nurse. When the defect consists in a quali- 
tative deterioration of the milk, which not only renders it in- 
adequate and unsuitable as an aliment, but endangers the life 
of the child, improvement is not within the resources of art or 
science, and weaning is the only remedy. It frequently hap- 
pens, however, that the qualitative changes are only tempo- 
rary, due to some well-known fault on the part of the mother. 
In such instances it may be necessary to withhold the breast 
from the child until the cause has been removed, but perma- 
nent weaning should not be advised or permitted. 

The wonderful preservative, influence of breast milk, and 
the baneful effects of the want of good breast milk, are shown 
by the following results of the observations of Drs. Merei and 
Whitehead of 1,041 children. 



THE MORTALITY OF YOUNG CHILDREN. 



127 



1. u Children having had breast milk 



3. 



4. 



5. 



r Well developed 

' -^Medium developed 
alone to ninth month or longer." / r> ii i i \ 

" Children who have had breast"] 

milk up to sixth, eighth, and ninth J Well developed . 

month; after which they were )■ Medium developed 

partially weaned, and received j Badly developed . 

other food." J 

" Those having had breast milk^ T -, 7 T1 , , , 

,° Well developed . 

moderately abundant and bread »« -.. , , , 

J . . V Medium developed 

food along with it from birth or £„ devel d . 

early age. ■> 

" Children from birth or the age of 

two or three months, besides an 

abundance of breast milk, had 

received boiled bread and milk ; 

or merely water, sugar, and ar- 
row root." 
"Children having had from ear-^i 

liest infancy a moderate or small j 

supply of breast milk ; some for a 



Well developed . 

\- Medium developed 

Badly developed . 



Well developed 



6. 



x .i i .i £ i ^Medium developed 

lew months only, others for much ! L 

longer times, with other food j Bad1 ^ develo P ed ■ 

from birth." J 

, Well developed . 
» Children fed entirely by hand, J Medium deve i ped 
and with no breast milk at all." J Ba(]ly developed . 



62.6 per cent. 
23.3 per cent. 
14 per cent. 

58 per cent. 
26 per cent. 
16 per cent. 



51 per cent. 
25 per cent. 
24 per cent. 



52 per cent. 
28 per cent. 
20 per cent. 



26.5 per cent. 
26.3 per cent. 
47.9 per cent. 

1 per cent. 
26 per cent. 
64 per cent. 



The pernicious influences and extraordinary mortality pro- 
duced by the want of breast milk is more fully exhibited 
in the reports of foundling hospitals. In the hospitals of 
Lyons and Parthenay, France, where the children (Kouth) 
are suckled at the breast, the mortality is respectively 53.7 
and 85 ; whereas in Paris, Rheims and , where arti- 
ficial feeding is very generally employed, the mortality is 
respectively 50.3, 63.9, and 80 per cent. The observations of 
Drs. Merei and Whitehead show that the percentages of the 
medium and badly developed increase with the diminution of 
the breast milk and shortening of the period of lactation, 
until it reaches respectively 26 and 64 among those dry- 
nursed from birth. They show the equally important fact 
that additional food, when the mother is healthy and has an 



128 . THE MORTALITY OF YOUNG CHILDREN. 

abundance of milk (compare classes 1 and 4), reduces the 
percentage of the " well developed " from 62.6 to 52. These 
are the results among living children. The number of deaths 
from similar causes may be estimated upon the basis of the 
mortality in foundling hospitals. 

The foregoing data demonstrate the importance of preserv- 
ing to the nursling the breast of the mother. It is best when 
sufficient for its sustenance, but better even when insufficient 
than none at all. " The worst," says Routh, " that can be 
done under ordinary circumstances for a child, is to bring it 
up exclusively by hand ; at least, in the way in which it is 
usually done." He asserts, furthermore, that " the mere sub- 
stitution of a hired wet-nurse increases the mortality " and 
cites in proof, in addition to others, the circumstances that in 
Switzerland and Holland, where the smallest number die, the 
mothers nurse their own children ; and " of one hundred chil- 
dren suckled by their mothers, in Paris, eighteen die in the 
first year ; of the same number at nurse, twenty-nine die." 
In the department of the Gironde are two communes, under 
similar hygienic conditions. In one the mothers suckle their 
own children ; in the other a number of mercenary wet- 
nurses take in children from Bordeaux in large numbers to 
nurse. In the first the mortality is 13 per cent, in the last it 
is 89 per cent. 

In view of these considerations the preservation of the func- 
tion of the mammary gland, and its restoration when impaired, 
becomes a duty of paramount importance. The more general 
diffusion among women of information concerning the causes 
of defective lactation, and the importance of early recognition 
of and attention to the evil effects, will accomplish much 
towards modifying or obviating the dangers. 

The general management of cases of defective lactation 
consists in local or mechanical, hygienic, dietetic, and medical 
treatment. A discussion of the details of these several 
methods would involve an elaborate and unprofitable review 
of the literature of a subject concerning which a vast amount 
of nonsense has been written, and for the treatment of which 



THE MORTALITY OF YOUNG CHILDREN. 129 

many remedies have been recommended, both by physicians 
and laymen, with which the writer has had no experience, 
and of the value of which there is no confirmatory evidence. 
Nevertheless, the subject is too important to be passed with- 
out comment. 

The local treatment involves the management of the gland 
and nipples before and after labor. Any disease of the gland, 
or irregularity in shape or position of the nipple, should re- 
ceive the necessary attention before or during pregnancy. 
Sore nipples and sore breasts are quite common, and some- 
times unavoidable, occurrences after confinement ; but with 
proper care and timely treatment they are usually manage- 
able affections, and do not necessarily permanently disturb 
the function of the gland. 

Various local and mechanical means have been emplo} f ed 
to provoke and increase the flow of milk. Suction, titillation 
of the nipple in imitation of the process of milking animals, 
pressure, kneading, gentle friction, electricity, fomentations, 
and the application of various stimulating substances have 
been employed, with more or less success. Of these, suction 
and electricity have yielded the most favorable results. Suc- 
tion is the most certain and powerful means of promoting, 
increasing, and preserving the lacteal secretion. This is illus- 
trated by the numerous instances of maidens and barren 
women, and of the few cases of males, who have by this 
means established a copious secretion of milk ; by the cases 
reported by Livingstone, Dunglison, Thorwarth, Waddy, and 
others, of old women, who had long before ceased to men- 
struate and bear children, who had reproduced the secretion, 
and nursed their grandchildren ; and by the very common 
occurrence, — the gradual, sometimes rapid, loss of the milk 
after the death of the child, notwithstanding the efforts made 
to preserve the breast for mercenary considerations. The 
preferable mode of suction is by the child. There are sundry 
contrivances for this purpose, but unless handled by experts 
they are more often productive of harm than good. Regular 
and methodical nursing of the baby will often, especially in 



130 THE MORTALITY OF YOUNG CHILDREN. 

the cases of natural scantiness of flow and torpor of function, 
promote the secretion, and in those cases of defective lactation 
due to insufficient, irregular, or over-nursing it will frequently 
completely restore the gland to its normal condition. 

Electricity has not been so extensively employed ; but in 
the hands of those who have given it a fair trial the results 
have been encouraging. It is a valuable adjuvant to suction. 
It stimulates the nerve distribution and circulation, and pro- 
motes the nutrition of the gland. 

The local treatment of the gland by the application of plas- 
ters, ointments, oils, embrocations, and poultices, for the cure 
of any form of defective lactation, is, so far as is known to 
the writer, useless. 

The hygienic treatment refers to personal and domiciliary 
cleanliness ; healthy exercise in the open air ; proper sleeping 
apartments ; sufficient and refreshing sleep ; fresh and pure 
air ; protection from the debilitating influence of a continuous 
high temperature, and from the equally injurious effects of 
severe cold ; and sufficient and proper clothing. The change 
of residence from town to country, or to sea-shore, sometimes 
promotes an abundant flow of good milk. In short, the 
hygienic rules and regulations which are so conducive to the 
health of nurslings are equally important for the mother. 

The dietetic treatment is the most important of the several 
methods, and yields most satisfactory results. This is so gen- 
erally recognized, both by laymen and physicians, that it is 
almost exclusively employed. There is, however, no universal 
diet suitable to every mother, no continuous regimen of speci- 
fied foods which can be relied upon in every case with a uni- 
formity and constancy of results. The general law governing 
the dietetic management is to supply such foods as are simple, 
nutritious, easily digested, and easily assimilable, and to avoid 
such as may be injurious to the nursling. It is worse than 
useless to attempt to sustain life, and at the same time nurse 
a baby, upon crude articles, knickknacks, candies, preserves, 
pickles, and bonbons, together with teas, ptisans, and pota- 
tions. The watery constituent may be increased, but the nu- 



THE MORTALITY OF YOUNG CHILDREN. 131 

tritive quality of the milk will be deteriorated. A judicious 
combination of animal and vegetable foods is always desirable. 
Strong salt foods and indigestible and acescent fruits and 
vegetables should be avoided. Potatoes and other vegetables, 
in which oxygen and hydrogen exist in the proportion to form 
water, such as the starchy, saccharine, gummy, and ligneous 
varieties, should be used in moderation. Neither should the 
diet be exclusive^ albuminous. Fats in moderation are bene- 
ficial. Oatmeal and barley are generally admissible. Fish, 
tender birds, crabs, and oysters are considered specially effi- 
cacious. Routh commends whiting soup and conger-eel soup 
as milk-producing foods. Among the vegetable aliments 
many varieties have from time to time been extolled as valu- 
able agents to improve the flow and richness of the milk, but 
most of them have been relegated to the usual disuse of over- 
estimated specifics. Among this class, Routh regards the len- 
til, pea and bean soup, and among the edible fungi, the deer 
balls, as the most efficacious promoters of the secretion of 
milk. The influence of turnips is familiar to every one accus- 
tomed to use milk ; but no one prefers the milk of cows fed 
on turnips, nor do puny babies thrive on the milk of mothers 
fed on any of the brassica species of vegetables. 

The proper dietary management of puerperal women, espe- 
cially during the earlier days of the month, will influence 
favorably the lacteal secretion. The practice in times past, 
and one too common now, of limiting the diet of a recently 
confined woman, during the first week, to tea and toast, or 
some other equally innutritious aliment, has given way to a 
more generous system of feeding women who have to live 
themselves and feed others. The process of making milk in 
the laboratory of one's own person must consume a large 
amount of force, which can only be replenished by food. 

There is great diversity of opinion in regard to the value 
of drinks. Perhaps the rule which governs most persons is 
the special fondness for a particular beverage. Good, pure, 
wholesome drinking water, in requisite quantities, is certainly 
unexceptionable and harmless ; and perhaps equally as effi- 



132 THE MORTALITY OF YOUNG CHILDREN. 

cacious as the more valued and palatable compounds and mix- 
tures of alcohol. Stimulating and appetizing drinks are some- 
times very efficient promoters of digestion ; but no healthy 
nursling needs alcohol, and, when sick and needing it, it had 
better be fed from the spoon than nursed from an intoxicated 
mother. 

To even enumerate the medicines, disgusting compounds, 
and nauseous mixtures which have been suggested, employed, 
and extolled as galactopoetics 1 by their inventors and dis- 
coverers would be a waste of time and space. No one but 
themselves has ever witnessed the benefits which their enthu- 
siasm has so lavishly bestowed. The simple rule of guidance 
in the medical management of cases of defective lactation is 
to address the remedies to the improvement of the health of 
the mother. If her digestion is impaired, blood impoverished, 
or bowels sluggish, meet the indications with the appropriate 
remedies. Heal old sores ; cure chronic discharges ; arrest 
hemorrhage. Restore her, if possible, to the condition of a 
vigorous and healthful woman in the prime of life. So far as 
this is accomplished, so far will all be done that can be to re- 
store the sufficiency and richness of the milk. 

The removal of the cause of insufficient and unfit mother's 
milk and the restoration of the function of the organ con- 
stitute the most conservative and certain method of supple- 
menting the natural aliment of the infant. In this aspect of 
the question the sanitarium can accomplish a vast amount of 
good. The improved hygiene and regimen, together with 
the salutary influences of change of residence, and freedom 
from the cares and sorrows of want and destitution, with such 
medical advice and medicines as a careful and skilled expert 
may deem needful, will prove successful in very many cases. 

Supplemental alimentation must necessarily be considered 
in two other and very different aspects ; one relates to the 
supply of additional food which most children need after the 
appearance of the eight front teeth ; the other to those cases 

1 Substances to which has been attributed the property of favoring the 
secretion of milk and augmenting its quantity. 



THE MORTALITY OF YOUNG CHILDREN. 133 

in which the mother, from some one or more of the unremova- 
ble causes previously enumerated, has failed to furnish ade- 
quate sustenance, either from birth or during the earlier 
months of lactation. It is demonstrated that not only does 
the composition of the milk change materially as the period 
of lactation advances (see Table XV.), but the infantile or- 
ganism usually demands, after that age, more nutriment than 
most women can supply. How best supply the deficiency is 
an important question. Common sense would reply, with 
the milk of another woman ; but common experience teaches 
that this method is not only inexpedient and impracticable, 
but is pregnant with untold evils to the defenseless nursling. 
The mercenary wretch who sells her breast and thus robs her 
own child of its birth-right, leaving it to suffer, or perhaps 
starve, and often abandoning or destroying it, is not fit either 
morally or physically to properly nourish any other child. 

The model wet-nurse should be a woman of suitable age 
who has lost her own child at about the same age as the foster 
child. She should have a breast of good and abundant milk ; 
be free from actual or hereditary predisposition to disease, 
possess a kindly disposition and even temperament ; have no 
vicious, gluttonous, lazy, or uncleanly habits ; and finally, be 
animated by a love of children rather than the money value 
of her services. When such an one can be had, she will 
measurably fill the mother's place. In the sanitarium, to 
which will be admitted a number of mothers with nursing 
babies, it may happen that some will possess a superabundant 
flow of good milk, which can, with great propriety (barring 
always the objections just stated), be used in aid of those in- 
sufficiently nourished, but the institution cannot engage in 
the immoral and criminal business of making wet-nurses, or 
hold out inducements for them to make themselves. Wet- 
nursing will then, practically, be limited to the mothers pos- 
sessing a superabundance of milk, who may temporarily re- 
side in the institution, and who will furnish a wholly inade- 
quate supply. The deficiency must be mainly supplied by 
artificial lactation. 



134 



THE MORTALITY OF YOUNG CHILDREN. 



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THE MORTALITY OF YOUNG CHILDREN. 135 

ARTIFICIAL LACTATION. 

Artificial lactation means the substitution of animal milk 
for that of the mother, and is applicable to three very dif- 
ferent classes of young children : — 

(1.) The motherless, the abandoned, and those whose moth- 
ers are wholly incapacitated for nursing. 

(2.) Those who are insufficiently nourished by their mothers 
from birth or during the earlier months of life. 

(3.) Those who are insufficiently fed because of their ad- 
vanced age and rapid growth. 

As milk is the only natural, it should be the exclusive, diet 
of infants until after the appearance of the eight incisor teeth. 
The milk of an animal is the only suitable substitute for, or 
addition to, breast-milk which is generally applicable to the 
artificial lactation of classes one and two. There may occa- 
sionally occur an exception to this general law, due to some 
digestive idios}mcrasy of the infant ; but most frequently the 
exception is only apparent and properly attributable to some 
impropriety in the management of the baby, or some mistake 
in the preparation or preservation of the milk. After the 
cutting of the front teeth the three classes become practically 
one, designated as the third in the above classification, for 
which milk should be the chief, but need not be the exclusive, 
aliment. 

Cow's and goat's milk have been almost exclusively em- 
ployed as substitutes for that of the woman. Cow's milk is 
preferable, because it is more abundant, more easily obtained, 
and is free from any disagreeable odor. The proportion of 
water and solid ingredients in the milk of the goat (see Table 
XVI.) differs less from that of woman than does that of any 
other animal. The milk of all, excepting the ass, contains a 
larger quantity of solid constituents, the cow's containing 
more casein, butter, and salts, but less sugar, than that of 
woman. To adapt the milk of the cow to the purposes of 
artificial lactation, the proportions of the solids and water must 
be approximated to the percentages found in human milk. 



136 THE MORTALITY OF YOUNG CHILDREN. 

TABLE XVI. — Moleschofs Analyses of Milk. 





Woman's. 


Cow's. 


Goat's. 


Sheep's. 


Ass's. 


Mare*s. 


Water 


889.08 


857.05 


863.58 


839.89 


910.24 


828.37 


Solid ingredients . . 


110.92 


142.95 


136.42 


160.11 


89.76 


171.63 


Casein 


39.24 


48.28 


33.60 


53.42 


20.18 


16.41 


Albumen 


- 


5.76 


12.99 


53.42 


20.18 


16.41 


Butter 


26.66 


43.05 


43.57 


58.90 


12.56 


68.72 


Sugar 


43.64 


40.37 


40.04 


40.98 


57.02 


86.50 


Salts 


1.38 


5.48 


6.22 


6.81 


57.02 


0.29 





This is done by adding water and sugar, and should be, as a 
rule, according to the age of the nursling, and the corre- 
sponding changes which take place in woman's milk from 
month to month, as shown by the analysis (see Table XV.) 
of Vernois and Becquerel. This law cannot, however, be 
followed in every case, for infants differ very much in diges- 
tive and assimilating capacities. Most frequently too little 
water and too much sugar are added. It often happens that 
the quantities of sugar and water added must be varied from 
day to day until the proper proportions are ascertained by 
the evidences of relief and subsidence of digestive disturbance. 

Human milk is alkaline ; cow's milk is acid, but least so 
when the animal is pasture fed. Zahan, Stohmann, and Kerl 
believe the acidity is due to some change occurring in the 
udder of the cow. Be that as it may^ the practical fact is 
that it is generally, if not always, acid, and that the acidity 
increases continuously from the time of milking. Conse- 
quently the addition of antacids is a necessary part of its 
proper preparation as a suitable aliment for children; and this 
is the more necessary because of the constant tendency of milk 
sugar to transformation into lactic acid, and the danger of ex- 
cessive formation of acids in the stomach. 

The casein of cow's milk coagulates in firm and dense 
masses, that of woman's in loose and flocculent ones ; hence 



THE MORTALITY OF YOUNG CHILDREN. 137 

the latter is more easily digested. The more stale and acid 
the milk, the quicker and firmer the coagulation. Skimmed 
milk when taken into the stomach coagulates sooner than the 
same before the separation of the cream, because of loss of fat 
and other consequent changes. Various suggestions have been 
made for obviating these objections, but none have fulfilled 
the object. Perhaps, as remarks Jacobi, there is no way of 
making the casein of cow's milk any more digestible than it 
is as found in the natural condition. 

Cow's milk contains more butter than woman's, hence the 
greater tendency to the formation of the fat-acids, which are 
so frequently the cause of digestive disturbances in bottle-fed 
infants. Many unsuccessful experiments have been made to 
equalize the percentages of casein and butter found in the 
milk of the cow with those existing 'in human milk. The ad- 
dition of cream has proven detrimental. Fats are not di- 
gested in the stomach, but in the intestines, where they meet 
the bile, intestinal and pancreatic secretions. The formation 
of fat acids in the stomach and their admixture with the pan- 
creatic fluid neutralizes its property of emulsifying and prepar- 
ing the fats for absorption, producing intestinal indigestion. 
Intestinal digestion, at best, is feeble in infants, especially so 
in very young nurslings. Wegscheider has shown that the 
fat of the mother's milk is never completely absorbed, a part 
passing through the intestinal tract as fat, a part being sapon- 
ified, and a third part escaping in the form of fat acids. 
The writer believes that he has quite frequently successfully 
treated intestinal indigestion, both in infants and adults, by 
the addition of Dobell's pancreatic emulsion x to the milk. 
When the excessive formation of fat acids cannot be success- 
fully arrested by alterations of the proportions of water and 
sugar, and the addition of alkalies, it may become necessary 
to withhold the milk, and substitute rice or barley water, for 
several days. It will frequently be judicious to add to the 
milk a fluid prepared from barley or oatmeal ; the former 

1 A saline essence of pancreatine has been recently introduced by 
Savory and Moore of London, which promises favorable results. 



138 THE MORTALITY OF YOUNG CHILDREN. 

when diarrhoea is present, the latter when constipation exists ; 
bnt when the addition of either is made the quantity of milk 
should be diminished. 

Butter, which is present in so much larger proportion in 
cow's than in human milk, seems, both from experimental in- 
vestigation and clinical observation, to be the constituent most 
productive of digestive disturbances. Notwithstanding the 
diligent efforts that have been made, this difficulty has not 
been overcome. The addition of a sufficient amount of water, 
better too much than not enough, is so far the only practica- 
ble method suggested. As a rule milk is the only fluid a 
young baby ever gets, and generally, especially in hot weather, 
this furnishes an insufficient supply of water for the purposes 
of the animal economy. Water is as necessary as food ; in 
fact digestion cannot be carried on, nor can health be main- 
tained, or life sustained, without it. But it is not necessary 
to convert a child's alimentary tract into a common funnel, 
through which all the liquids and slops at a housekeeper's 
command are to be poured. 

How much milk should be given a child, and how best to 
feed it, are very important questions. The statistics of Merei 
and Whitehead show conclusively that over-feeding is detri- 
mental, and clinical experience proves as conclusively that 
over-feeding diminishes the expectancy of life. The quantity 
must of course bear some relation to the vigoivof development, 
and, therefore, a general rule can only be approximately ac- 
curate. The prevailing error, especially among the better-to- 
do classes, is to over-feed. 

Authors do not agree in regard to the quantity required by 
a healthy baby. Dr. W. H. dimming 1 has estimated the 
amount ordinarily furnished by a healthy woman to be from 
one and a half to two quarts daily. He thinks that an infant 
three months old will consume from forty-eight to sixty-four 
ounces daily, in six or eight half pint doses. Routh 2 thinks 
this estimate too high. He asserts that a child three months 

1 Routh, Infant Feeding, page 101. 

2 Amer. Journ. Med. Sci., vol. xxxvi., page 25. 1858. 



THE MORTALITY OF YOUNG CHILDREN. 



139 



old will generally thrive on five meals a day, the quantity 
taken at each meal not exceeding eight ounces. A younger 
child would nurse oftener, but the quantity would not exceed 
three ounces at each meal, so that from birth to the comple- 
tion of the third month the amount would vary from thirty- 
two to forty ounces daily. After that age the child may 
take forty-eight ounces daily. MM. Guilliot and Lamperiere 
(Routh) have shown that infants can absorb in twenty-four 
hours from forty-eight to sixty-four ounces ; and Hervieux 
insists that the} 7 thrive best when they take all they can ap- 
propriate, which he believes is a larger quantity than gener- 
ally supposed. Boussingalt's experiments on animals lead to 
the conclusion that infants require proportionately more food 
than older children or adults. 

The proportion of strong and healthy mothers who will yield 
an abundant supply of milk may be approximately conject- 
ured from the calculations of Merei and Whitehead. See 
Table XVII. 



TABLE XVII. — Supply of Breast-milk in 952 Women. 







*L% 




_>. 


£>£ 




u 

CD 

a 

3 

a 


abundant mi 
months and u 

rds, some t\ 

irs. 


a 

Fh 

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ft 

a 
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a 

a 
P 
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a 

4) .T2 

a a 


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a . 

eS e3 
p 

pM CD 

III 




3 


n * d £ 


o 


"S* 


"Sol 




< 




PL, 


M 


a 


Strong and healthy . 


629 


420 


66.7 


114 


95 


Delicate and sick . . 


323 


88 


27.2 


69 


166 ' 


Total .... 


952 


508 


" 


183 


261 



Thus it appears that 66 per cent, of mothers are strong 
and healthy ; of these 66.7 per cent, furnish milk in abun- 
dance, and 46.G per cent, of all mothers supply inadequate 
sustenance. 



140 THE MORTALITY OF YOUNG CHILDREN. 

Artificial lactation may be performed with the spoon, mug, 
or nursing bottle ; the last is the preferable method. The 
bottle should be one with a smooth and even internal surface, 
without shoulder, angles, corners, or inverted bottom, to which 
should be adjusted, by means of the stopper, a flexible tube, 
with a soft mouth-piece, and attached at the distal end to a 
glass tube within the bottle. 1 When the child has been fed, 
any remaining portion of the prepared milk should be thrown 
away, the different parts of the nursing apparatus separated, 
thoroughly cleansed, and laid aside in an alkaline solution. 
Many artificially nursed babies are annually sacrificed through 
omission of these apparently trivial matters. Coagula of 
milk attached to any part rapidly undergo such changes as 
will spoil the milk at subsequent feedings. When the child 
ceases to suck at the mouth-piece the bottle should be re- 
moved, and the child should not be urged to continue taking 
food when it has enough ; nor should it be allowed to hold 
the bottle any longer than is necessary, or dally and play with 
it, sucking and quitting, or sleeping and waking, with the 
mouth-piece held between its lips. The warmth of the body 
and hand, and the lapse of time, favor and hasten the deterio- 
rating changes which are so liable to occur in the milk. 

Dewees 2 insists that "the child should not receive its 
nourishment while lying ; it should be raised, which will not 
only become a pleasanter position, but it also diminishes the 
risk of strangulation." Routh 3 asserts that the semi-erect 
position, which is that occupied when nursing at the breast, 
is not only the most convenient, but, for anatomical reasons, 
the best. After having been fed the child should be allowed 
to rest, sleep, if it will, and not be jostled up and down as if 
one desired to convert its stomach into a churn. The practice 
is injurious and productive of much mischief. No less repre- 
hensible is the familiar habit of rudely and quickly tossing, or 

1 The bottle sold by Rey riders & Co., and described by Jacobi, in his 
essay on Infant Hygiene, is perhaps the best. 

2 Dewees on Children, paragraph 575. 

3 Infant Feeding, page 97. 



THE MORTALITY OF YOUNG CHILDREN. 141 

swinging by its shoulders, a child high in the air. It is grati- 
fying, however, to know that the stomach sometimes retaliates 
by pouring out its contents upon the chief performer in such 
acrobatic sports. 

Dewees says milk should never be boiled, and Jacobi is op- 
posed to its being given raw. The former asserts that the for- 
mation of the pellicle by boiling deprives it of a part " of one 
of its most valuable constituents." Parmentier and Deyeux 
concluded from their experiments that the loss of the volatile 
principle by boiling was disadvantageous ; others hold the 
opposite opinion. No one doubts that boiling will diminish 
the tendency to decomposition and. acidity, and will some- 
times restore alkalinity. Gas is also disengaged, and. the tend- 
ency to the formation of lactic acid is thereby diminished. 
Boiling also diminishes the absorbing power of milk, and de- 
stroys mold and germs. The absorption power of milk is 
very remarkable. If raw milk is placed in closed apartments 
with highly flavored fruits and vegetables, as for instance the 
orange or cantaloupe, it will rapidly absorb the flavor. How 
far this property of absorption may prove detrimental has not 
been determined. These considerations lead manifestly to the 
conclusion that heating the milk, especially in warm weather, 
is essential to its preservation. The writer has not adopted 
either of the extreme opinions, but has preferred a medium 
course. As soon as the milk is received (and there should 
always be at least a morning and evening supply of fresh 
milk), it should be prepared by the addition of hot water, in 
quantity sufficient together with the alkali for the proper di- 
lution. It should then be placed, in a covered vessel, in a 
refrigerator, and as needed the required quantit}^ is warmed 
and sweetened with white (not brown) sugar. This process 
of scalding the milk has appeared to secure all the benefits of 
heat, and when the other necessary attentions — perfect 
cleanliness and purification of every utensil employed, and of 
the place of keeping — were carefully carried out, has usu- 
ally proved satisfactory as a method of preservation. Many 
healthy children from eight to twelve months old, and older, 



142 THE MORTALITY OF YOUNG CHILDREN. 

will take milk without any dilution, and thrive. In such 
cases it is best to add a very small quantity of boiling water, 
or to simply boil it. 

CONDENSED MILK. 

Condensed milk has been very extensively employed as a 
substitute for breast-milk, and there exists a great contrariety 
of opinion in regard to its value. Daly and Jacobi, perhaps, 
represent the two extremes of opinion : the former believes 
that all children fed upon it are weakly, and possess a feeble 
power of resistance to disease ; the latter holds, that when 
mixed in proper proportions with barley water or oatmeal 
gruel, according as diarrhoea or constipation may be present, 
it is quite as good " as ordinary city milk " prepared in a 
similar manner. The writer's experience differs somewhat 
from that of either of these gentlemen, and this difference re- 
lates to the peculiarities of infants. When prepared as rec- 
ommended by Jacobi and largely dilated, it has, in very many 
cases, proved sufficient, but in a larger number of cases it has 
proved unsuitable. It has seemed, at times, to cause thrush 
and diarrhoea ; and it is undoubtedly true that some infants 
fed exclusively upon it manifest a feeble resistance to mor- 
bific agencies, but this is very far from being the general 
rule. 

OTHER SUBSTITUTES. 

As a matter of fact there is no such substance as a substi- 
tute for milk. It is true that many children have been reared 
without ever having tasted breast-milk. The statistics of 
Merei and Whitehead, before cited, show that of those fed 
exclusively on breast-milk to the ninth month or longer, 14 
per cent, were badly developed ; and in 23.3 per cent, the 
development was only medium ; while of those " fed entirely 
by hand and with no breast-milk at all," only 10 per cent, 
were well developed. The conclusion is thus quite apparent 
that feeding exclusively on breast-milk does not always pro- 
duce the best results, but it is even more apparent that the 
exclusion of breast-milk from birth yields the worst results. 



THE MORTALITY OF YOUNG CHILDREN. 143 

The substitution of animal for human milk is the alternative 
best adapted to the artificial feeding of classes one and two 
(see page 135), but it is alleged there are occasional instances 
when infants cannot be nourished with milk. Such cases are 
so rare that the writer cannot recall a single instance occurring 
in his own practice. The cases in which milk should be with- 
held for a time, especially during the hot summer months, are 
numerous among those infants who have not passed the pe- 
riod of the appearance of the incisor teeth. How best to nour- 
ish such infants is a problem that has not yet been solved. 
Arrow-root, tapioca, sago, and many other farinaceous sub- 
stances have been very generally abandoned. The " sugar- 
teat," corn-starch, and " cracker- victuals " ought to be univer- 
sally condemned. The various manufactured and patented 
" Infant Foods " are mere articles of traffic, as unsuitable as 
they are unreliable. Occasionally an infant in vigorous health 
is exhibited as an illustration of the remarkable nutritive 
virtues of some one of these unknown compounds; but it is 
more probably the exhibition of a development attained in 
spite of them. When the cause is an evanescent one, it should 
not be forgotten that total abstinence from food, and some- 
times from drink, — stomachal rest for a period, — will prove 
sufficient to restore the function of digestion ; and when to this 
can be added rectal alimentation, the period of stomachal rest 
may be prolonged. In such cases the decoction of barley and 
oatmeal gruel, of the farinaceous substances, have been gen- 
erally preferred, because of their large percentage in protein 
compounds, and (Jacobi) richness in salts. But, notwith- 
standing the protest of Jacobi against the use of rice water, 
the experience of the writer coincides with that of Trousseau 
in regard to its value. He has too often witnessed its bene- 
ficial effects in cases of diarrhoea with uncontrollable vomiting 
in young infants, to abandon its employment on mere theoret- 
ical grounds. The eau albmnineuse 1 of Trousseau ; the gel- 

1 Prepared by diluting the whites of four eggs with a quart of water ; 
sweetened to taste by adding sugar, and aromatized with orange-flower 
water. 



144 THE MORTALITY OF YOUNG CHILDREN. 

atine food of Meigs ; 1 and Liebig's Infant Food will serve a 
good purpose as temporary expedients in many cases. But, 
as previously stated, a diligent and persistent effort to adapt 
good fresh milk in some form, either by varying the dilution 
or the preparation of some compound of which it is the basis, 
will in a vast majority of such cases be crowned with success. 

Animal food is rarely, if ever, admissible to the dietary of 
infants under six or eight months. Healthy children are very 
frequently supplied with animal food before the cutting of the 
teeth begins, in fact during the earlier months, without detri- 
ment, but it is always a hazardous experiment. In cases of 
sickness, especially in that class of diseases usually compre- 
hended under the designation of " summer complaint," ani- 
mal food is more often a cause than a preventive of death. 
When necessary or admissible, broths, teas, essences or ex- 
tracts prepared from beef are to be preferred. 

The supplemental and artificial alimentation of young in- 
fants constitute one of the most important problems which 
must engage the attention of the sanitarium. No such oppor- 
tunity has ever before been presented for the study of this sub- 
ject. To execute the trust confided to the management, the 
whole subject of infant diet must be reopened and reexamined 
in the interest of preventive medicine. Speculations and sug- 
gestions are simply the result of individual observation and 
experience, which are only valuable in so far as they may 
present a reasonable hypothesis upon which more extended 
and scientific experiment and investigation can be conducted. 
The field is not less inviting than it is rich in results which 
will contribute to the diminution of the mortality and allevia- 
tion of the suffering of young children. 

DENTITION. 

The preceding sections on supplemental alimentation and 
artificial lactation have been devoted mainly to the discussion 
of alimentation of infants classed in the first and second sub- 
divisions (see page 135), and for the period of life termi- 
1 Diseases of Children, Meigs and Pepper, page 304, ed. 1870. 



THE MORTALITY OF YOUNG CHILDREN. 145 

nating with the beginning of dentition. The second period 
is characterized by the eruption of the twenty deciduous 
teeth, and extends to the twenty-fourth or thirtieth month 
of age. During this period all children, sooner or later, 
should be weaned, and will require additional and different 
food. Previous, therefore, to the consideration of the influ- 
ence upon mortality of weaning and feeding, it is proper to 
consider the relation of dental evolution to the progress of 
growth and development in infantile life. These teeth ap- 
pear in successive groups. The period of appearance of these 
groups has been variously stated. The writer's observations 
coincide with the results obtained by Drs. Merei 1 and White- 
head, which Routh also accepts. There are, however, very 
many exceptions to this general law both in the time and 
order of the appearance of the members of the separate 
groups. The beginning and progress of the eruption of the 
teeth is very generally accepted as the index of progressive, 
and delayed dentition as the evidence of retarded, develop- 
ment. Merei and Whitehead state that in 79 per cent, of the 
well developed, the first teeth appeared before the eighth 
month had passed ; while in 60 per cent, of those with unfa- 
vorable development " the first were cut at eight months and 
upwards." As it is the almost universally accepted belief 
that the appearance of the first tooth is the proof that veg- 
etable foods can be allowed, it appears from these data that 
in a large majority of infants the eighth month is the earliest 
period at which such food would be a suitable addition to the 
diet. At that time the progressive development of the organs 
of digestion has sufficiently advanced. The salivary and pan- 
creatic secretions, and the gastric and intestinal fluids, are 
capable of digesting some vegetable aliments. The inference 
is equally apparent also that even trivial indiscretions in diet 
may at this period induce grave disturbances of the alimentary 
tract ; for it does not follow that because nature by such posi- 
1 Anterior incisors, seventh month ; lateral incisors, ninth month ; ante- 
rior molars, twelfth month; canine, eighteenth month; posterior molars, 
two years. 

10 



146 THE MORTALITY OF YOUNG CHILDREN. 

tive evidence has indicated that the child is maturing, that 
therefore it can be fed indiscriminately with vegetable foods. 
As the several groups of teeth appear at distinct and succes- 
sive periods, and at intervals varying from two to six (stated 
approximately) months, what relation, if any, do these alter- 
nating periods of time in the child's life bear to the digestive 
disturbances which are so common during the age of dental 
eruption ? The process of dental evolution is a physiological 
one beginning during intra-uterine life, and should be pro- 
gressive until completed. Yet it is the common belief that 
with the appearance of the first tooth begins the era of disas- 
ter, and that the acme of danger is coincident with the erup- 
tion of the several groups. This does not seem to be a 
rational conclusion. The sacs of both the milk and perma- 
nent teeth are formed during intra-uterine life, the ossification 
of the former dating back as early as the fifth month of that 
period. By continuously increasing growth upwards, the 
crowns of the front incisors appear above the alveolar borders 
of the jaw at or about the seventh month, and are followed at 
somewhat regular periods by the others in successive order. 
The evolution is a continuous process from the beginning of 
the formation of the dental sac and papilla, and progresses 
pari passu with the development of the entire digestive appa- 
ratus. Why should the periods which mark the completion 
of each part of a continually progressive physiological process 
be periods of greater danger than the intervals of equal activ- 
ity in the development of these incompleted parts ? The fact 
is that all children are teething from the moment of birth un- 
til they have cut their last posterior molar ; and it is not true 
that the periods of eruption are any more conducive to bowel 
disturbances than the intervals. The statistics of mortality 
show conclusively that alimentary disorders are far more fre- 
quent and more fatal during the months preceding the eruption 
of the teeth than during any period of an equal number of sub- 
sequent months. Dental evolution and eruption are not any 
more frequently the cause of disease than the simultaneous and 
consecutive evolution of the other and more important parts 



THE MORTALITY OF YOUNG CHILDREN. 147 

of the digestive apparatus. It so happens that the appear- 
ance of a tooth is an object of distinct observation fixing a 
period of time, whereas the changes that are taking place in 
the glands and alimentary tract progress in an uneventful 
succession. Again, if this- natural process is so destructive of 
infantile life, it should be equally so in winter as in summer ; 
in the farming regions as in populous cities ; among the well- 
to-do as among the destitute ; in an equable as in a vari- 
able climate, during the periods of dental eruption which 
occur during the other months as during those which occur in 
July ; and in Philadelphia as in the neighboring cities of New 
York and Brooklyn. Why should it be so destructive at a 
given locality during one season and so much less so the suc- 
ceeding summer? Why more disastrous to children, at a 
given age, weaned, than to those nursed, at the same age ; to 
the wet-nursed than to those nursed by their mothers ; to 
those partially or wholly fed artificially than to those fed ex- 
clusively on breast-milk ; to the abandoned and motherless, 
who are carefully and tenderly nursed in well arranged and 
appropriately constructed asylums, than to those rudely man- 
aged at home, but supplied with abundant and good breast- 
milk ? All these circumstances, which are but the restate- 
ment of facts previously narrated, go to show the fallacy of 
the prevalent opinion that the eruptive periods are times of 
unusual danger. Nevertheless, authors of very high repute 
continue to reassert the doctrine. Meigs and Pepper assert 
that they " have rarely observed cholera infantum before the 
beginning of the process of dentition, and very rarely after its 
completion." J. Lewis Smith says, " it usually occurs under 
the age of two years." In 282 cases in which the observations 
were made, 47 had no teeth, and 28 had all the teeth. The 
statistics of Dr. Emerson show that it is more fatal in the first 
year than in the second, thus contrasting the causal influence 
of the very rapid growth of the first year with the more active 
eruption of the teeth during the second. In 138 children 
at the Necker Hospital, during the first dentition, Bouchut 
says, 26 were free from all indisposition, 38 had transient diar- 



148 THE MORTALITY OF YOUNG CHILDREN. 

rhcea, and 46 had abundant diarrhoea ; in 19 it appeared at 
the time of swelling of the gums and ceased with it, to re- 
appear with the subsequent eruption of teeth. Yogel, who 
confounds entero-colitis with cholera infantum, under the 
designation of intestinal catarrh, says, " in children over one 
year of age the process of dentition is the most frequent 
cause," and " that the ordinary looseness of the bowels, which 
usually accompanies dental evolution, may become cholera- 
like, and prove fatal in twenty-four hours." West deduces 
the general conclusion " that the greatest prevalence of diar- 
rhoea and dysentery coincides exactly with that time during 
which the process of dentition is going on most actively," and 
asserts that half of his cases occurred between the ages of six 
months and two years. Bouchut says, " the influence of den- 
tal evolution upon the diseases of the alimentary canal is com- 
pletely established." So constant and active an influence does 
Trousseau consider dentition that he insists that weaning 
should not be completed prior to the eruption of the fourth 
group, and that it should never be terminated suddenly. Eus- 
tace Smith says the bowels are, during dentition, " ripe for diar- 
rhoea," because of the augmented irritability growing out of 
the increased development of the follicular apparatus ; *' but, 
without the presence of the ordinary exciting causes, diarrhoea 
is by no means a necessary result of such a condition of the ali- 
mentary canal." No one will deny the occurrence of fever, 
and, occasionally, of convulsions, in cases of difficult dentition, 
and that the congested condition of the gums and inflamma- 
tory state of the buccal mucous membrane may extend to 
the intestinal mucous membrane and set up increased peri- 
staltic action for all parts of the alimentary canal, and of its 
dependencies, which are undergoing active evolution to fit 
them for the proper assimilation of the varied food on which 
the voun^ beinor will soon have to subsist. All these consider- 
ations point to the conclusion that it is the relation subsisting 
between alimentation and the physiological evolution of the 
digestive organs and their dependencies which is so easily dis- 
turbed during the period of life when nature is preparing the 
organism for an independent and self-sustaining existence. 



THE MORTALITY OF YOUNG CHILDREN. 149 

WEANING AND FEEDING. 

It matters not whether the conclusion reached in the pre- 
ceding section, or its converse, that dentition is the constantly- 
prevailing factor, be the correct one, the accommodation of 
the diet to the changing condition of the organism must be 
equally important. The cutting of the teeth marks the stage 
of development at which the supply of additional aliment is 
usually required, and during which the gradual preparation 
of the digestive apparatus for the duties of self-support should 
be completed. The deprivation of breast-milk and the addi- 
tional feeding should both be gradually accomplished. Wean- 
ing, unless rendered imperatively necessary by some condition 
either of the mother or child, should not be completed before 
the eruption of the fourth group of teeth, from the twelfth to 
the sixteenth month of age. It is best, as a rule, that it 
should not be done during the heated months of the year. 
Many intercurring circumstances and conditions, some of 
which have been previously referred to, may determine an 
early or a late weaning. When practicable, and it is practica- 
ble with the greater number of infants, the digestive function 
should be accustomed to some form of farinaceous food be- 
fore the beginning of weaning. Milk made into a pap with 
wheaten bread, or thickened with wheaten flour, barley, or 
oatmeal gruel, will usually prove sufficient in the beginning, 
to be followed, when the anterior molars have appeared, by 
oatmeal porridge, or cornmeal mush, and milk, with the occa- 
sional allowance of good wheaten bread, the juice of fresh 
beef, meat gravies mixed with bread, or well cooked, ripe 
and mealy potatoes, and finally by a larger allowance of solid 
food, a moderate supply of tender meat, not over-done, scraped 
or finely minced ; but milk, or some composition of which it 
is the basis, must constitute the main reliance until the first 
dentition has been completed. 

The feeding of weaned children is second only in impor- 
tance to the alimentation of nurslings. The mere enumeration 
of suitable substances which may be allowed in successive 



150 THE MORTALITY OF YOUNG CHILDREN. 

order is often objectionable and will accomplish but very little 
good. Parents should, so far as may be possible, be made to 
understand the principles of alimentation. It is not probable 
that very many, especially among the ignorant classes, can be 
taught the minute anatomy of the various parts of the diges- 
tive apparatus and the correlation of the functions of the sev- 
eral parts; but most people are sufficiently intelligent to learn 
more than they now know. Example, observation, and prac- 
tice are wise and efficient instructors. Very many persons who 
know nothing of the principles of mechanics can be taught to 
work and handle certain machines with consummate skill. 
The chief obstacle to the proper instruction of parents in the 
principles governing the alimentation of children consists in 
the fact that these principles have not as yet been definitely 
ascertained and formulated. The whole subject is obscured 
by hypotheses, individual speculation, and unsatisfactory labo- 
ratory experiments. Very many interesting and important 
facts seem to be definitely established, but they are of little 
value to the general public because they have not been reduced 
to the practical methods of every-day uses. 

The first and most important lesson in the art of feeding 
children is to teach parents that they can learn all that it is 
absolutely necessary to know ; and the second is to disabuse 
their minds of the errors which ignorance, superstition, and 
bad example have inculcated. Every mother knows that 
milk is the natural aliment of babies, and that hand-feeding 
is always attended with more or less danger. They know 
equally well that the milk of an animal is the best substitute 
for breast-milk ; but they are generally ignorant of the most 
simple methods for the preservation and preparation of it. 
Over-feeding and feeding with unsuitable substances are the 
most frequent and gravest errors committed by parents. 
Merei and Whitehead have shown that over-feeding from 
birth reduces the percentage of well developed from 62 to 
51 per cent., and increases the percentage of the badly devel- 
oped from 14 to 24 per cent. It is equally disastrous if com- 
menced at a later period, and is far more frequent after the 



THE MORTALITY OF YOUNG CHILDREN. 151 

eruption of the incisor teeth. The over-fed are those most 
frequently fed on improper food. The commission of the first 
error leads to the second and more serious mistake. There is 
no such thing as an indifferent or negative aliment for young 
children. That which they do not need is detrimental. They 
need suitable and sufficient food, but do not seek savory dishes 
and unfit substances until their natural tastes and instincts 
have been perverted by the constantly repeated temptations 
of indiscreet parents. It is a prevailing error to allow young 
children to come to, or rather to force them to, the family 
table, and tempt them with bits of first one thing and then 
another, until they fret and cry for everything within reach 
or sight ; and when sickness follows, the parents are as re- 
luctant to acknowledge the cause of the bowel trouble as 
most adults are to confess that anything they eat ever makes 
them sick. 

The circumstances which should govern weaning relate first 
to the mother, second to the child, and third to the season of 
the year. 

In addition to the various conditions of defective lactation 
previously discussed, the mother is sometimes rendered ineli- 
gible from acute diseases either of a general or local charac- 
ter. Febrile and exhausting diseases, and acute inflammatory 
and chronic local affections of the mammaB and generative 
organs, unfit women for the duties of nursing, either tempo- 
rarity or permanently. Instances are also reported of women 
whose milk contained blood, pus, and other extraneous and 
poisonous matters. Whenever anything injurious to the 
mother is increased by suckling, or her milk becomes unfit, 
weaning is justifiable. 

On the part of the child, the state of the teeth and the 
state of its health must determine the period of weaning. 
The first has been considered in a previous section. It is 
never judicious to take the breast from a child while it is sick, 
or during convalescence, unless it is manifest that the milk of 
the mother is injurious. Even an inadequate supply will often 
be all-important for the nourishment of a child exhausted by 
sickness. 



152 THE MORTALITY OF YOUNG CHILDREN. 

The season of the year should be that in which the tem- 
perature is most equable, and which is most free from the 
bowel disturbances so prevalent in the summer months. The 
spring and autumn are the preferable seasons. 

In view of the relation subsisting between the evolution of 
the teeth and the digestive apparatus, the following conclu- 
sions may be stated : — 

(1.) There is no fixed age at which all infants ought to be 
weaned ; and only in exceptional cases should it be permit- 
ted previous to the appearance of the eye and stomach teeth. 

(2.) There is no routine diet suitable to all weaned infants, 
but the food must be adapted to the progress of development 
and the condition of the infant. 

(3.) The most effective preventive of the ill effects of im- 
proper and unsuitable alimentation of weaned infants will be 
the education of parents in the art and science of nursing and 
feeding. ' 

(4.) The age of exclusion from the domiciliary department 
of the sanitarium cannot be under the thirtieth month. 

THE MILK SUPPLY. 

The supply of milk must be obtained either by purchase, 
production, or a combination of both methods. The last will 
be the most desirable and expedient. 

That portion obtained by purchase must come from dairies 
at convenient distances from the institution, to avoid the in- 
juries of transportation, lapse of time before delivery, and ex- 
posure to the air. The dairy or dairies, (and it is best that 
the herds of animals should not be too large), should be con- 
ducted according to the most approved methods of feeding, 
pasturage, stabling, care, and milking of the animals. The 
dairymen and other necessary attendants should be scrupu- 
lously neat and clean. The vessels employed in milking, 
straining, and transportation should be inspected daily. Care 
should be taken to avoid every source of contamination from 
imperfectly cleansed vessels, careless attendants, filthy stables, 
unsuitable food, unfit or contaminated drinking water, disease 



THE MORTALITY OF YOUNG CHILDREN. 153 

among the cattle, and other extraneous sources of impregna- 
tion with the germs of disease peculiar to the human being, 
which have so frequently, of late years, been conveyed to 
large numbers of consumers of milk. The milk of every 
animal should be examined microscopically and chemically by 
a competent person, at times, if possible, unknown to the pro- 
prietor, and at the dairy before it is mixed with any other, 
that the good may not be contaminated by the bad. Each 
morning and evening supply should be carefully examined 
after delivery. 

The adulteration of milk is the common practice of dealers 
and dairymen. Becquerel and Vernois have discovered the 
following substances in the milk supplied to Paris : water, 
glucose, flour, starch, dextrine, infusion of rice, barley, and 
bran, yolk of egg and white of egg^ sugar, gelatine, liquorice, 
boiled carrots, broken down calves' brains, serum of blood, 
bicarbonate of soda, chalk, turmeric, emulsion of hemp or al- 
mond seeds, and other substances. In England Hassall found 
eleven out of twenty-six samples adulterated with water in 
the proportion of from 10 to 50 per cent. Sanderson found 
in all but one sample examined, excess of water. Hillier 
found the quantity of water added varied from 25 to 50 per 
cent. Thompson, Salter, and Hunt ascertained that the quan- 
tity of water usually added was one gallon to two of milk. 
The addition of water has proven even more detrimental than 
the mere dilution. The poison of infectious diseases has, in a 
number of instances, been added by its pollution with con- 
taminated water. Recent observation seems to show that 
epidemics of disease originating through the milk are very 
virulent. 

Parmentier and Deyeux maintain that " nothing 2 con- 
tributes more to maintain the good quality and quantity of 
cow's milk than scrupulous cleanliness in the sheds. If the 
refuse matters are left about and removed only at long in- 
tervals, the cows lying amid all this mess are always weak ; 
the udders are hot, and the milk, so susceptible of acquiring a 

1 Routh. 



154 THE MORTALITY OF YOUNG CHILDREN. 

bad odor, soon contracts a bad taste, of which it is with diffi- 
culty again deprived." Dr. Normandy found a herd of 
" thirty or forty cows in a most disgusting condition, full of 
ulcers, their teats diseased, and their legs full of tumors and 
abscesses ; in fact, quite horrible to look at ; and a fellow was 
milking them despite of all these abominations." Hillier ex- 
amined a number of cow-sheds, none of which did he find 
suitably located, properly ventilated, properly drained, or of 
sufficient capacity. Some were under inhabited dwellings, 
some with insufficient water supply, and some the common 
receptacle for every form of filth. In many the animals were 
too long confined, poorly fed, and otherwise ill used. 

Country milk differs from town milk ; summer from winter 
milk ; and morning from evening milk. In the country the 
animals are less crowded, have more exercise, and are not fed 
so exclusively on dry food. Winter milk contains less water, 
and evening milk is richer in cream. 

Milk is deteriorated by transportation, more so when the 
distance is long and the conveyance rough. Agitation causes 
separation into butter and butter-milk. This change is 
promoted by dilution. Exposure to the air sets up lactic 
acid fermentation. The sooner the delivery after milking the 
better the condition of the milk. 

The difficulties which may embarrass the purchase of milk 
are not insurmountable, but they will require all the care and 
vigilance of the officers in charge to detect and avoid. It will 
be wisest to suspect the cupidity of the dealer rather than 
rely upon his honesty. 

There are many other and equally important reasons why 
the institution should produce at least a portion of the neces- 
sary supply. Many of the questions which refer to the in- 
fluence of different food, amount of drinking water, weather, 
season, care, and attention of the animals, upon the quality 
and quantity of milk, need further investigation. The rela- 
tion of the condition, care, and food of the animal to the 
health and nutrition of the beneficiaries must also be care- 
fully studied. The alterations of the milk occasioned by the 



THE MORTALITY OF YOUNG CHILDREN. 155 

time and frequency of milking, by stall-feeding and pasturage, 
and by rest and exercise require examination. Experiments 
should be made to ascertain the kinds of food that will most 
closely approximate the milk of the animal to that of the 
woman. The advantages or disadvantages of a single cow's 
milk as the exclusive aliment of a child ; of feeding it directly 
from the animal, either by putting the child to the udder or 
as soon as convenient after it has been drawn from the animal, 
are questions as yet unsettled. Should the milk be protected 
from exposure to the air and carried, with least possible agita- 
tion, to the place of keeping, and there preserved by such 
means as may be best ; or should the children, at regular in- 
tervals, be carried to the place of milking and there be fed 
with the fresh and raw milk, before it has lost its natural 
aroma and warmth ? If the milk of an animal is the only 
proper and suitable substitute for breast-milk, may it not be 
as important to imitate as near as possible the manner and 
process of nursing as it is to approximate the constitution of 
the milk of the animal to that of the woman? Routh says, 
" the newer the milk is the better it is for the child," and ex- 
presses the belief that " immense advantage would accrue by 
allowing all infants to take the milk directly from the nipple 
of the animal." When practicable, he recommends that the 
animal " be brought to the door and then and there milked, 
and the milk in its fresh state at once given to the child." 
" Children will thrive under this mode of procedure when 
other means have failed." 

These investigations and experiments should not be con- 
fined to the milk of the cow. The milk of the goat more 
closely resembles that of woman than that of any other 
animal, and is believed by many to be preferable for the pur- 
poses of artificial lactation. Routh 1 relates the circumstance 
that " the foundlings of Dublin were very many years ago 
sent to the mountains of Wicklow, to feed upon the goats' 
milk. As the children grew older the goats came to know 
them, and became very tame ; so that the infant could go to 
1 Infant Feeding, page 311. 



156 THE MORTALITY OF YOUNG CHILDREN. 

the goat to be suckled by it, as it would to a human wet- 
nurse." The children throve remarkably well. A similar 
result is said to have been observed in Malta. 

To put in operation the suggestions in regard to the home 
production an immediate outlay will be required and the cur- 
rent expenses will be increased. Necessary stabling and 
other convenience must be provided, and competent and trust- 
worthy employees must be secured. Proper food must be 
purchased, or produced on the farm. A portion ought to be 
produced, and the pasturage should be supplied, at home. 
The herd need not be large, five or ten cows, and perhaps 
half that number of goats, will be sufficient for experimental 
purposes. The additional outlay in the beginning, and the 
increased current expenditure, is a small consideration in view 
of the immense advantages which may result. The manage- 
ment cannot neglect such an opportunity of contributing " to 
the best means of lessening the mortality and promoting the 
welfare of young children." 

LOCATION. 

The vastly greater prevalence of disease among infants, 
and the larger percentage of mortality in towns than in the 
country, are sufficient to show that the institution must be 
located in the country. The remoteness of the city of Balti- 
more from the sea-coast, and the insalubrity of the shores of 
the Chesapeake Bay, are decisive in favor of an inland 
locality. The high and picturesque region lying north and 
west of the city indicate the direction in which a location of 
sufficient elevation must be sought. The schedule of railway 
elevations running north and west show elevations varying 
from 400 to 800 feet at accessible distances from the centre of 
the city. The requirements of the site, as suggested in the 
circular of the trustees, may be stated as follows : — 

1. It must be on a steam railway, within one hour of 
the city, and the building site not over five minutes' walk 
from a station. 

2. The quantity of land should not be less than 100 acres, 



THE MORTALITY OF YOUNG CHILDREN. 157 

facing south and southwest, with no stagnant water, marshes, 
or mill ponds in the vicinity ; and a portion of it must be in a 
natural forest. 

3. The elevation must not be less than 600 feet above tide- 
water. 

4. A stream of water of sufficient capacity, in the driest 
season of the year, must be within available distance. 

5. The building site should possess the advantages of nat- 
ural drainage ; the soil should be porous. 

6. A portion should be good agricultural land, at least suf- 
ficient for pasturage and a kitchen garden. 

7. It should be in a healthy region, where the water is 
pure, and food of all kinds is abundant and cheap. 

TRANSPORTATION. 

Transportation must be by steam railway cars. The run- 
ning and general management of the trains must be left to 
the officers and employees of the road, but must be conducted 
in the interests of the institution, and in the manner most 
conducive to the comfort and welfare of its beneficiaries. 
Sick and invalid children ought not to be huddled pell-mell 
into an unfit coach, and dumped out at the place of destina- 
tion in the hurry of ordinary railway travelling. The accom- 
modations should be comfortable and ample ; the cars should 
be clean and well ventilated ; order should be maintained ; 
and all risk of danger should be avoided. Suitable and ample 
accommodations for their reception must be provided at the 
stations of departure and destination. 

The institution must provide for each train a prudent and 
competent agent, whose duties must be definitely prescribed. 
Discipline should be impartially but gently enforced from the 
reception to the discharge of the patient. 

Drinking water must be supplied at the place of reception 
and on the trains. Food must be supplied to the very young 
infants needing it. The inspection of the children should be 
thorough at the place of reception. Their bodies and cloth- 
ing should be clean, and every care should be taken to avoid 



158 THE MORTALITY OF YOUNG CHILDREN. 

the dissemination of contagious diseases. No child or attend- 
ant should be permitted to carry with them anything of the 
nature of food, beverage, or medicine. The control and man- 
agement of the beneficiaries must be absolute from their re- 
ception until their discharge. 

ORGANIZATION AND GENERAL PLAN OF MANAGEMENT. 

The supreme authority and direction should reside in the 
Board of Trustees, which should prescribe all rules and regu- 
lations relative to the discipline and internal management of 
the institution. It should issue all its orders through, its chief 
executive officer, who should be an experienced and competent 
medical man, and known as the physician-in-charge. 

The physician-in-charge should have the general superin- 
tendence of the active operations of the sanitarium. He 
should be the head and only one, and should receive his di- 
rections from the trustees, and be responsible directly to them. 
All assistants, clerks, nurses, servants, and employees should 
be subordinate to him. He should be provided with a suitable 
dwelling, paid an ample salary, and hold his office during good 
behavior, but be removable by the Board of Trustees for in- 
competency or neglect of duty. 

There should be one permanent medical assistant, who 
should be a competent microscopist and chemist. He should, 
under the direction of the physician-in-charge, conduct all 
chemical analyses and microscopic examinations, and perform 
such other duties as may from time to time be assigned to 
him. He should reside in and devote his entire time to the 
institution. His salary should be commensurate with his du- 
ties. 

There should be such temporary assistants as may be nec- 
essary, employed only for the time during which the sanita- 
rium is in active operation. They may, as experience will 
dictate, be either graduates in medicine or under-graduates. 
They should receive only such compensation as may be re- 
quired to meet their necessary current expenses. 

There should be one clerk to the physician-in-charge, em- 



THE MORTALITY OF YOUNG CHILDREN. 159 

ployed temporarily or permanently as may be found neces- 
sary. 

There should be employed permanently one head cook, and 
one head female nurse. The number of additional cooks and 
nurses must be determined by the number of beneficiaries. It 
will probably be found most expedient to permanently retain 
more than one efficient and thoroughly trained nurse, as it 
may be difficult to secure trained nurses for temporary service 
during the summer season, and the duties will be too impor- 
tant to be intrusted to incompetent and untrustworthy women. 

The number and selection of servants and employees should 
be left to the discretion of the physician-in-charge. Economy 
should be observed and efficiency should be required in every 
branch of the service. 

There should be appointed a board of consulting physicians, 
to serve without remuneration. This board should visit the 
institution at stated periods, and record, in writing, the results 
of their observation and inspection, with such suggestions as 
may be deemed proper and judicious for the better manage- 
ment of the institution. 

There should also be appointed annually a committee of vis- 
iting physicians, to be selected from the most distinguished 
physicians in different parts of the country, whose duty it 
should be to visit the institution at some stated time during 
the summer months, and thoroughly examine and inspect 
every branch of the sanitarium. This committee should report 
in writing to the Board of Trustees. This duty should be 
performed at a trifling cost, certainly not more than the actual 
travelling expenses of the members of the committee. One or 
more of this committee should be female physicians. 

The records of the institution should be full and complete. 
The age, sex, color, nativity, residence, and clinical and family 
history of every beneficiary should be accurately recorded. 

PEOVISIONAL SUGGESTIONS. 

In view of the fact that the sanitarium will be in active 
operation for only a portion of each year, some provision must 



160 THE MORTALITY OF YOUNG CHILDREN. 

be made for the employment of the permanent officers and 
employees during the greater part of the year. 

The permanent medical officers will find ample occupation 
in study, investigation, and original research, for the advance- 
ment and improvement of the institution, and in the prepara- 
tion of the annual reports. The institution owes something 
to the advancement of science, and it will be mainly, if not 
exclusively, through the efforts of these two officers that such 
contributions can be made valuable. The character and na- 
ture of these investigations have been very definitely indicated 
in the foregoing pages. 

How best to utilize the services of the permanent cook and 
nurses is not so easily answered. It occurs to the writer that 
the management will find it proper and necessary to establish 
in the city of Baltimore a depot or salesroom, where suitable 
articles of diet for young children may be sold at actual cost 
to the poorer class. In such case the services of these em- 
ployees in instructing those poor persons in the proper manner 
of preparing the food, and in feeding their infants, may con- 
tribute much towards lessening sickness and mortality. 

THE ADMISSION OE BENEFICI ABIES. 

It may not be wise to exclude any invalid child under five 
years of age from the benefits of the visiting department. 
None older should be admitted. Asylums, hospitals, and con- 
valescent establishments are the proper places for such chil- 
dren. 

To the domiciliary department, preference should be given 
in the order following : — 

1. To sick infants under thirty months of age. 

2. To those between thirty months and three years of age 
suffering from bowel diseases. 

3. To well children under thirty months. 

No child suffering from any contagious or infectious disease 
should be admitted. 

No mother suffering from any contagious or infectious dis- 
ease should be allowed to accompany her child. 



THE MORTALITY OF YOUNG CHILDREN. 101 

No mother who will refuse compliance with the regulations 
should be permitted to remain in the institution. 

No mother admitted to the institution should be permitted 
to pass her time in idleness. When able, and not engaged in 
the proper and necessary attention to herself, infant, and sleep- 
ing apartment, she should be required to perform such other 
work as may be conducive to her health. Sewing, knitting, 
washing, and ironing, will always be necessary. 

The management should carefully avoid the encouragement 
of pauperism, — an error which many benevolent institutions 
constantly commit. Those parents who are able to defray the 
expense of their maintenance, or a part thereof, should be re- 
quired to do so. A schedule of very moderate charges should 
be established for the information of the public and guidance 
of the officers. 

CLOTHING. 

Clothing must be provided for the sick children admitted 
to the domiciliary department. Before admission to their 
proper apartment their clothing should be removed, and, as 
soon as practicable, washed, disinfected, and put away, to be 
restored when discharged. The children should be washed 
and dressed, according to the regulations, before being con- 
veyed to the ward or sleeping-room. Great care is necessary 
with children confined to their beds, to protect them from the 
deleterious influences of their discharges. 

MEDICAL MANAGEMENT AND TREATMENT. 

The medical care and treatment of the sick must be left to 
the judgment and discretion of the physician-in-charge and 
his assistants. It must be assumed that these officers will be 
competent in every respect to discharge all such duties. None 
others should be selected or retained. 

If the duties of the physician-in-charge and the professor- 
ship of the diseases of children in the medical department 
of the Johns Hopkins University could be united in the same 
person, both institutions would thus be enabled to command 
11 



162 THE MORTALITY OF YOUNG CHILDREN. 

the services of a man of the highest order of ability and pro- 
fessional acquirements. Such an arrangement would contrib- 
ute to the success of both institutions, and to the advancement 
of knowledge concerning the causes and treatment of those 
diseases from which such an alarming mortality annually 
occurs. 

The medicines needed will be few and simple. It may, 
however, be important that one of the temporary assistants 
should have sufficient knowledge of pharmacy to fit him for 
the compounding and preparation of prescriptions. 

BUILDINGS. 

As the sanitarium proper will be open only during the 
warmer months of the year, the buildings intended exclusively 
for occupancy by the beneficiaries, and by the officers and 
employees, should be constructed solely with reference to use 
during the summer season. They should be plain, simple, 
cpmfortable, and inexpensive wooden structures, as fol- 
lows : — 

Two private dwellings, one each for the physician-in- 
charge and the permanent assistant physician. 

An administration : building, with two wards arranged as 
wings for the accommodation of those infants who may not be 
accompanied by their mothers. 

" The plan of the first floor, the designation and dimensions 
of rooms, and the positions of doors, chimneys* windows, and 
beds, are shown on Plate A ; the plan and dimensions of the 
second floor on Plate B ; the front and side elevations of the 
building on Plate C ; the sections are shown on Plate D." 

The first floor should be raised several feet above the sur- 
face of the ground, on piers or open arches. The spaces be- 
tween these piers or arches should be filled with lattice-work. 

" A good cistern of suitable capacity should be constructed 
and connected with the gutters and eave spouts. 

1 For the details of description and specifications of this plan, see Cir- 
cular No. X., Surgeon General's Office, War Department. It is the plan 
of the present Army Post Hospital. 



THE MORTALITY OF YOUNG CHILDREN. 163 

" The windows should be furnished with outside shutters. 

" The privy and dead-house should be removed one hun- 
dred feet from the building. 

" All the doors should have transoms." 

There should be a number of cottages for occupancy by 
the mothers accompanied by their infants. These may be 
constructed with two, four, six, or eight rooms on the same 
floor. They should be one story, and elevated above the 
ground. The rooms may be arranged in a single row, the 
doors opening upon a wide veranda, or in double rows, with 
doors opening into a wide covered hallway open at both ends. 
All the doors should have a transom ; all the windows outside 
slat shutters ; and all the rooms a fireplace. They need not 
be plastered, but should be constructed in a substantial and 
workman-like manner. They should be sufficiently removed 
from each other to afford ample space, and abundant fresh air 
and sunlight. Too much shade should be avoided. The 
water-closet and sink arrangements should be entirely discon- 
nected. 

At a convenient distance from these cottages the general 
kitchen should be erected, where all the food for the mothers 
and their children, and for the excursion parties, should be 
prepared. A dining-room should be directly connected with 
the kitchen, bat no child should be allowed to enter it at the 
meal-times of the mothers, nor should the mothers be permit- 
ted to carry to their rooms any article of food prepared for 
themselves, or give it to their children. The children need- 
ing it should be fed at regular intervals, under the super- 
vision of a nurse, either in the dining-room or at their lodg- 
ings. 

The buildings for the visiting class should be convenient to 
the general kitchen, but should be entirely distinct and sep- 
arated from the cottages by an inclosure sufficient to prevent 
the two classes from commingling. These buildings should 
be constructed on the pavilion style, with benches and other 
necessary appurtenances pertaining to a picnic resort, such 
as are usually provided by the German associations on the 
grounds where their annual festivals are held. 



164 TEE MORTALITY OF YOUNG CHILDREN. 

At a convenient distance from the cottages and festival 
buildings, the bath-house should be erected and provided with 
all necessary conveniences for hot and cold bathing, both for 
adults and children. 

The laundry should be remote from all inhabitable build- 
ings. 

The ice-house should be of ample capacity. 

On another part of the grounds should be erected a number 
of single cottages, each with sufficient accommodations for a 
small private family, for occupancy by such persons as are 
able and willing to defray their own expenses, and who may 
wish to avail themselves of the salutary influences of a coun- 
try health-resort. It is not improbable that many parents, 
with young children, may prefer, if suitable accommodations 
are provided, a health-resort which will supply all that is 
essential to the proper care and treatment of young children 
during the season when a residence in the city is so hazardous 
to infants. 



ON THE IMPROVEMENT OF THE CONDITION 
OF THE POOR AND SICK CHILDREN: GEN- 
ERAL PRINCIPLES. 

A Letter to the Honorable the Board of Trustees of the Thomas 

Wilson Sanitarium for Children. 

/ 
BY A. JACOBI, M. D., 

New York. 

Gentlemen, — You favored me with a note dated Balti- 
more, December 8, 1879, in which you honored me with the 
request to write an essay on the best method of establishing 
a sanitarium (not a hospital, but a summer retreat) for sick 
children. At the same time you also desired my opinion 
regarding the regulations suitable for receiving and adminis- 
tering medically and otherwise to those who would be the 
proper objects of your care, with such suggestions as might 
occur to me in reference to the character of the buildings that 
might be requisite, their grouping, or isolation ; how best to 
provide for mothers or nurses accompanying their children ; 
and generally such incidental recommendations as experience 
and reflection might commend as valuable and useful. 

You also wish my suggestions in reference to the most prac- 
ticable means of lessening the risks and changes incident to 
children exposed to the heated and impure atmosphere of a 
large city during the summer months ; also my views as to 
the best methods of extending a general knowledge of simple 
hygienic rules for the treatment of children at home among 
the poorer classes. And while you express your hope, " at 
least, to show a model of experiment," which may prove of 
value as a contribution to the best means of lessening the mor- 
tality and promoting the welfare of young children in Balti- 
more, and in other large cities, you direct me to give my 



166 IMPROVEMENT OF THE CONDITION OF CHILDREN. 

thoughts in the method and manner which I shall deem most 
conducive to their successful presentation. 

All these questions and demands I look upon as in perfect 
harmony with the objects of your corporation, when first es- 
tablished. For though a summer retreat was mainly contem- 
plated by the originator of your vast plan of benevolence, the 
general object was to " alleviate pains and to prolong life." 
And while a summer retreat for sick children was mentioned 
as the one prominent end to be reached, other kindred pur- 
poses, as might be hereafter determined upon by the corpora- 
tion, were included in the points to be gained. 

Thus, the original intention of Thomas Wilson, and your 
specifications, questions, and demands, comprehend a vast 
amount of important matter. Not only do you ask for the 
best means of extending the knowledge of simple hygienic 
rules for the nursing and treatment of children, — which are 
the same for those of the rich and the poor, white and black, 
Christian, Gentile, and Infidel, — but you desire to provide 
for those who are well, so as to protect them from sickness ; 
for the sick, to cure them ; for those, in particular, who suffer 
from impure air and heat, so as to save them ; and also ask 
for plans and specifications. While I express my fear that I 
may not be able to say anything new, and my doubt whether 
I can do justice to the subject as understood by you, I am 
gratified, at least, by the fact that you do not expect to cor- 
rect a great universal evil by a single remedy or by a single 
method. Benevolent efforts avail but little, as a general 
thing, because they are directed against special evils, which 
are either the outgrowth of a false system or but a link in 
a chain. The breadth of your views includes the desire to 
benefit the poor children, be they well or sick, — as they are 
almost certain to be, because they are young ; and more so 
because they are poor. The latitude, however, extended by 
you to the expression of my views, renders my task very diffi- 
cult ; because, to do it justice, extensive discussions upon the 
hygiene and diet of infants and children, the physiology of 
their digestive and other systems, the influence of heat on 



IMPROVEMENT OF THE CONDITION OF CHILDREN. 167 

their nerves and blood, and upon the condition of their food, 
the essential points in their diseases, and the rates and reasons 
of their mortality, might be expected. Fortunately, the main 
principles of many of these points are settled ; and therefore 
my remarks can, in part, be fragmentary. There are a num- 
ber of truths which, by this time, are considered self-evident; 
and strictly scientific questions, which are still undecided, do 
not belong here. 

The class of people to be benefited by your corporation are 
the poor and sick children. The main attention is to be paid, 
however, to the children threatened by, or suffering from, the 
heat of the summer and impure air, both of which not only 
affect the nervous system directly, but destroy life by acute or 
chronic affections of the alimentary canal. 

To what class and age do they belong ? And is it mainly 
the heat, or mainly the impure air, or mainly the food, which 
destroys them ? Which of these factors is most objectionable 
and preventable ? And are there no other factors of excessive 
infant mortality which can be obviated ? 

Of 100 newly-born babies, 16 or 18 will die before they are 
a year old in most countries. In England, of 100 born to the 
gentry, there lived after a year, 90 ; tradesmen, 79 ; working 
class, 68. 

Of 1,000 dead in the first families in Germany, 57 were 
under five years of age ; amongst the poor of the capital 
there were 345. 

In the starvation years of 1841 to 1851, the population of 
Ireland decreased by 19.8 per cent., the number of children 
under five years by 37 per cent. 

The average mortality of the new-born in France up to the 
completion of their first twelve months is 16 per cent. ; in 
four of the districts to which infants of Paris are sent for 
nursing purposes, it was 25.63, 30.28, 27.62, 51.33 per cent., 
while the mortality of babies born in these very same dis- 
tricts, and less neglected by the women, was less frightful. 

Of Paris babies sent to the country for nursing and rear- 
ing purposes, and strictly superintended by the proper au- 



168 IMPROVEMENT OF THE CONDITION OF CHILDREN- 

thorities, 17 per cent, died before the end of the first year, — 
that is, but one per cent. beyond the average mortality of that 
age in France. Of the babies sent out by private societies, 
with the same pay and regulations, not officially watched, 
however, 42 per cent. died. The foundlings of the Departe- 
ment Eure et Loire, who were bottle fed, and in many in- 
stances a number of them in charge of a single woman, from 
60 to 75 per cent, were destroyed before they reached the end 
of their first year ; many of them never had their faces lit by 
a smile. Of 1,000 children in France, an average of 554 
reached their tenth year ; of 1,000 French " assisted chil- 
dren," but 271. That babies at the breast suffer less, and 
fewer die, than those raised on artificial food, is a common- 
place experience and statistical fact which need not be insisted 
upon any further. That the nature of the artificial food, — 
a single meal of sour milk, or indigestible farinacea, — swells 
the lists of deaths, is well known. 

It was mainly the injurious feeding which, with the over- 
crowding, resulted in the heart-sickening rates of mortality 
amongst the population of the Prague foundling asylum. It 
was 82.97 per cent, in 1857 ; 90.46 in 1858 ; 87.07 in 1859 
86.95 in 1860; 89.71 in 1861; 88.79 in 1862; 93.19 in 1863 
72.52 in 1864 ; 62.46 in 1865 ; 60.14 in 1866 ; 54.07 in 1867 
46.68 in 1868 ; 46.08 in 1869. 1 

Lessened mortality of the infant under a year depends to a 
great extent on favorable external circumstances, sufficient 
food and its appropriate selection. When Menier insists upon 
the rate of mortality depending upon the intellectual cult- 
ure of the people, he forgets, in behalf of his bright saying, 
that intellectual culture and abject poverty do not go hand in 
hand, but that the former requires the foundation of physical 
comfort and ease. 

Of 100 deaths taking place in the total population of Eu- 
rope, 26.5 per cent, were under a year ; 5.6 from 1 to 2 ; 2.6 
from 2 to 3 ; 1.8 from 3 to 4 ; and 1.35 from 4 to 5 years old. 

Such is the average of all classes in all seasons. 

1 A. Jacobi, " On Foundlings and Foundling Institutions," Med. Rec- 
ord, N. Y., Nov. 15, 1872. 



IMPROVEMENT OF THE CONDITION OF CHILDREN. 169 

Of 2,216 infants who died under a year in Baltimore dur- 
ing 1875, the number of those who died in June, July, and 
August was 984, equal to 44.5 per cent., instead of 25. Of 
705 who died between their first and the end of the second 
year, there were in the same months 200, equal to 29 per 
cent., instead of 25. Of 508 between the second and fifth 
years, 110. Thus the months of June, July, and August 
proved very murderous to the population of infants under a 
year, to a certain extent so for those between the first and 
second years. Those between the second and fifth years were 
rather safe from the influences which destroyed the very 
young infants. Their main mortality was in the first quarter 
of the year 202 out of 508, a fact the repetition of which in 
almost every year directs the attention of every student to 
those causes of sickness and death which are apt to develop 
in the colder season, — that is the period of closed doors and 
windows, and epidemic influences. 

Of 2,317 infants, of less than a year, who died in Balti- 
more in 1876, the same quarter, namely, June, July, and Au- 
gust, took off 53 per cent, of the whole number, instead of 25. 
Of 2,182 in 1877, 48.3 per cent. ; of 1,834 in 1878, 40 per 
cent. 

Of 925 children of more than a year and less than two 
years, who died in 1876, the same quarter took off 33 per 
cent, of that number ; in 1877, 35.3 per cent, of 1,329 ; in 
1878, 29 per cent, of 604, instead of 25 per cent. 

Of 398 children of more than two and less than five years, 
who died in Baltimore in the whole year 1876, the same quar- 
ter of the year destroyed 18 per cent. ; in 1877, 23.6 per cent, 
out of 578 ; in 1878, 24 per cent, of 444. 

The months of June, July, and August, with their high 
temperatures and diarrhceal diseases, with all their conse- 
quences, destroy large percentages of the babies under two 
years of age, mainly those of less than one year, while the 
greatest mortality of the children of from two to five years 
depends on other causes, and takes place in other seasons. 

Of a total mortality of 4,070 in the city of New York, in 



170 IMPROVEMENT OF THE CONDITION OF CHILDREN. 

the four weeks ending on July 17, 1880, there were 1,962 in- 
fants under one year ; under two years, 2,451 (1st to 2d 
years, 489) ; under five years, 2,641 (2d to 5th years, 190). 
In these four summer weeks the mortality of infants under a 
year amounted to 48.2 per cent. ; under two years 60 per 
cent. ; under five, 64 per cent, of the total mortality. The 
mortality of babies under a year was about equal to the total 
average mortality for the whole year of all diseases under 
ten years. 

The statistical proofs, which might be accumulated indefi- 
nitely, show only what we know too well, that the heat of 
the summer destroys life in uncommon numbers, and mostly 
where the air is not only hot, but also impure. And they 
prove also that it is mainly the infants under two years who 
suffer from the effects of the season, through its influence 
on the alimentary canal. It is mainly those in their first 
year who are liable to be affected by digestive disorders, while 
those in the second are more decimated by respiratory dis- 
eases ; this is contrary to the prevailing impression, which at- 
tributes the majority of digestive disorders to the second year, 
and mainly the second summer. This belief is an incorrect 
one, and not founded on facts. The second summer is in it- 
self not more dangerous than the first, on the contrary ; for 
morbility and mortality decrease from day to day after birth. 
The youngest is the most liable to fall sick and die, and mor- 
tality decreases with every day, week, and month. It is not 
the second summer which kills the baby, it is after the child 
has been weaned, the sour cow's milk, the ice-water, the candy, 
the green apple, the short socks, the partaking of all, as 
mothers will proudly state, " that is on the table." 

The mistakes in the diet of young children and its injurious 
effects are the results of both the ignorance on the part of the 
mothers as to what constitutes a proper nourishment, and the 
difficulty of obtaining it either fresh or unadulterated. Igno- 
rance cannot be cured at once ; in regard, however, to the fea- 
sibility of supplying the poor infants of a large community 
with wholesome, fresh, and unadulterated food, I desire to 
make a practical proposition. 



IMPROVEMENT OF THE CONDITION OF CHILDREN. 171 

Again I insist upon the fact that the part of the population 
which is subject more than any other to acute disease and 
chronic ailment, consequent upon improper feeding, is below 
two years of age ; that at that age mortality is greatest, and 
depends mainly upon diseases of the alimentary canal. It is 
therefore the food required for the first two or three yeais for 
which my suggestions are meant. Now, infants' and chil- 
dren's food has a peculiarity which renders a sufficient and 
wholesome supply very easy to obtain. They require no va- 
riation, no stimulants, under ordinary circumstances, and with 
the exceptions to which I shall have to allude, no spice, no 
mixture. Day after day, month after month, the baby takes 
the breast, sucks the bottle ; the child takes his plain food, the 
same every morning, noon, and night, without longing for a 
change, refusing it, even, and, thriving, gains weight and spir- 
its. Thus the bill of fare for babies and children is a very 
simple and short one, easily obtainable, and, as a rule, easily 
procured but for the heart! essness of trade. And this very 
heartlessness of trade, the recklessness with which the conse- 
quences of deception, as far as the health of the community in 
general, and of the little children in particular, is concerned, 
are disregarded, is the reason why I desire that some means 
should be found through which an adequate supply of whole- 
some food could be placed within reach of every infant and 
young child of the poor classes. 

The safest food for an infant is the breast milk of either its 
mother or wet-nurse. The latter is out of the question amongst 
the babies of the poor. Where no breast milk can be had, or 
the supply is insufficient, substitutes must take its place. As 
soon as weaning becomes a necessity, that is, under ordinary 
"circumstances, after a few teeth have made their appearance, 
artificial feeding has to take the place of the natural supply. 
The articles of food remain the same for a long time, no 
change being required except as far as a gradual increase in 
the consistency of the meal is concerned. 

What this nourishment should be I have mentioned in my 
work on " Infant Diet," 1 and in my essay on " Infant Hy- 
1 First ed., 1872; Second ed., 1875. 



172 IMPROVEMENT OF THE CONDITION OF CHILDREN. 

giene," in the first volume of the "Handbook of Hygiene," 
edited bj Dr. A. H. Buck. 1 The rules I laid down in these 
publications are the result of no mere theoretical combinations, 
but the outgrowth of my experience through a quarter of a 
century, and are borne out by chemical facts and the teach- 
ings of infant physiology. In the hands of the Board of 
Health of the city of New York, by whom they have been ex- 
tensively published and distributed in the beginning of every 
summer, for the last seven years, they are known to have 
done much good ; they have certainly done so in my prac- 
tice. 

They read as follows, with the judicious official additions 
mainly under III. : — 

RULES FOR CARE OF INFANTS. 

Health Department, ) 

No 301 Mott Street, New York. ) 

At a meeting of the Board of Health, held June 3, 1873, the fol- 
lowing series of rules (approved by many physicians) for the man- 
agement of children during the hot season, with a view to prevent 
the large annual mortality of this class, was submitted by the Sani- 
tary Committee, and ordered to be printed : — 

I. Nursing of Infants. 

Over-feeding does more harm than anything else ; nurse an infant 
a month or two old, every two or three hours. 

Nurse an infant of six months and over, five times in twenty-four 
hours, and no more. 

If an infant is thirsty, give it pure water, or barley water, no 
sugar. 

On the hottest days a few drops of whiskey may be added to 
either water or food ; the whiskey not to exceed a teaspoonful in 
twenty -four hours. 

II. Feeding of Infants. 

Boil a teaspoonful of powdered barley (ground in coffee-grinder) 
and a gill of water, with a little salt, for fifteen minutes ; strain, then 

1 New York, 1879. 



IMPROVEMENT OF THE CONDITION OF CHILDREN. 173 

mix it with half as much boiled milk, add a lump of sugar, size of a 
walnut, and give it lukewarm, from a nursing bottle. Keep the 
bottle and mouth-piece in a bowl of water when not in use, to which 
a little soda may be added. 

For infants five or six months old, give half barley-water and half 
boiled milk, with salt and a lump of sugar. 

For older infants, give more milk than barley-water. 

For infants very costive, give oatmeal instead of barley. Cook 
and strain as before. When your breast-milk is only half enough, 
change off between the breast-milk and this prepared food. 

In hot weather if blue litmus-paper, applied to the food, turns 
red, the food is too acid, and you must make a fresh mess, or add a 
small pinch of baking-soda. Infants of six months may have beef- 
tea or beef-soup once a day, by itself, or mixed with other food ; and 
when ten or twelve months old, a crust of bread and a piece of rare 
beef to suck. 

No child under two years of age ought to eat at your table. 

Give no candies, in fact nothing that is not contained in these 
rules, without a doctor's orders. 

III. Summer Complaint. 

It comes from over-feeding and hot and foul air. Keep doors and 
windows open. 

Wash your well children with cool water twice a day,- or of tener in 
the hot season. 

Never neglect looseness of the bowels in an infant ; consult the 
family or dispensary physician at once, and he will give you rules 
about what it should take and how it should be nursed. Keep your 
rooms as cool as possible, have them well ventilated, and do not allow 
any bad smell to come from sinks, privies, garbage boxes, or gutters 
about the house where you live. See that your own apartments are 
right, and complain to the Board of Health, 301 Mott Street, if the 
neighborhood is offensive. Where an infant is cross and irritable in 
the hot weather, a trip on the water will do it a great deal of good 
(ferry-boat or steamboat), and may prevent cholera infantum. 
By order of the Board, 

Chas. F. Chandler, President. 

Emmons Clark, Secretary. 



174 IMPROVEMENT OF THE CONDITION OF CHILDREN. 

The object then, is to place a full supply of infant food 
within the reach of every infant or young child. The arti- 
cles are : — 

Powdered barley, or powdered oatmeal, sugar, milk, eggs 
(for children of about a year and over), in about the follow- 
ing quantities : — 

Powdered barley, a package of a half pound for a child 
under a year, every week. Two such packages for a child 
from one to two years of age. When oatmeal is required, the 
latter in place of barley. 

Eggs, seven a week for a baby a year old, or less ; fourteen 
a week for a child over a year old. 

Sugar, a half-pound a week. 

Milk, twelve ounces to a baby under a year, twice a day ; 
twenty ounces to those over a year, twice a day. 

In regard to milk only, there is a difficulty ; adulterations 
can be avoided by watching and examining, but the influence 
of heat on cow's milk is such that it is hard to avoid ; during 
the hot days there is danger of acidity and fermentation. 
Cow's milk, when leaving the udder, is but rarely alkaline at 
the best; the transformation of its milk sugar into lactic acid 
takes place very rapidly, and a single failure in procuring sweet 
and proper milk may be the cause of disease and death. 

As this is so, while the frightful mortality from improper 
food is explained easily enough, the efforts to avoid it must be 
permanent and persistent. 

I propose that your body should have and superintend a 
place or places in the city of Baltimore, where the infants and 
young children of the poor class can purchase the simple, 
though sufficient and ample, articles of food. If there be an 
expense to be risked for your fund at all, it would be for rent 
and saleswomen. But this expense may as well be borne by 
the purchaser, for I do not propose that the whole population 
should be a receiver of alms. From a humane and an econom- 
ical point of view only, I insist that the poor should be ena- 
bled to buy, in absolutely good quality and at a fair price, 
the necessaries of life and health. It is they who are more 



IMPROVEMENT OF THE CONDITION OF CHILDREN. 175 

liable to be deceived as to quality and price in all they buy, 
therefore they ought to be protected. Thus, whatever the 
infant requires in the way of food ought to be bought by those 
who are responsible for it, at a fair price, — be the responsible 
party the working man who supplies his family, or society 
who sustains its members not provided with family support. 

Your stock of cow's milk during the summer must be large 
enough for your summer sanitarium. One good cow will sup- 
ply the milk for five babies and five children over a year old. 
It can, however, be kept at any figure high enough to yield a 
full supply of good milk transported to the city twice daily, 
for all those infants and children coming under the provisions 
of this arrangement. If all the milk you sell to the infants 
and children in Baltimore comes from your own farm, you are 
sure of the article you sell, provided you know that your cans 
are always cleaned and washed out with soda solution, and 
your help always trustworthy. In case you have to purchase 
milk, you require additional watching. While admixture of 
water alone does not harm milk except by diminishing its rel- 
ative value both as merchandise and nutriment, it is still a de- 
ception to be guarded against, and admixtures and adultera- 
tions will always require the application of proper tests. 

Though I expect that fresh milk would be supplied twice 
daily, souring may take place so rapidly that I think proper 
to guard against it, at all events in the hot summer months. 
I recommend that the milk be not sold in its raw condition, 
but boiled at once. Without going into the chemical and 
physical reasons for that step, I simply refer to the unmistak- 
able fact that boiled milk keeps better than raw milk. Yet 
another step may be taken in the same direction. I propose 
that an addition of bicarbonate of sodium be made to the 
milk sold by you for infant food in the proportion of one in a 
thousand. This small quantity will retard the souring of 
milk somewhat, and the addition of the sodium salt to cow's 
milk, and its farinaceous admixture (with its superior amount 
of potassium) renders the milk sold by you a little more sim- 
ilar to mother's milk in regard to the chemical constituents of 
its salts. 



IMPROVEMENT OF THE CONDITION OF CHILDREN. 

Barley, oatmeal, and sugar are to be sold in ready made 
packages. 

This sale of food ought to be a permanent affair, and not 
limited to the summer months only ; for though the influence 
of summer heat is certainly most detrimental, in connection 
with improper feeding, this alone, at any time, is the main in- 
jury to infants and young children, endangering their whole 
future life. Mortality is great from diseases of the alimentary 
canal in winter as well ; and though they are not fatal to the 
same extent or number, the amount of permanent harm done 
to the digestive organs, lymphatic glands, and powers of assim- 
ilation after apparent or partial recoveries can be judged only 
from the large class of dyspeptics and prematurely decrepit 
persons, both pl^sieally and mentally, who owe their ailments 
to chronic or acute abdominal disorders of their early years. 

The persons to whom the sale could be trusted would be 
best selected from such help in your summer sanitarium as 
you would care to give permanent employment to, because of 
their intelligence and usefulness. The localities would be 
either a small store or stores, rented for the purpose, or a part 
of a store in a convenient part or parts of the city, be they 
groceries, or apothecary shops, or a part of, or a place adjacent 
to, a dispensary building. 

Persons applying and being regularly supplied from your 
stores ought to be known as deserving the privilege. Those 
who have been inmates of the sanitarium during a season 
would be recognized at once as entitled to being served. The 
poor, who are attended in dispensaries, can easily prove it. 
Such, however, as have not required medical treatment for 
some time can soon prove their claim by a note from some 
neighbor, or a physician. At all events, care should be taken 
lest that part of the population who, under the present ar- 
rangements of society, must be expected to pay a certain legit- 
imate percentage of profit to the class of traders, should not 
avail themselves of undue advantages by crowding your legiti- 
mate customers out of their rights and privileges. The well- 
to-do and rich have more facilities in guarding against being 



IMPROVEMENT OF THE CONDITION OF CHILDREN. 177 

deceived and overreached, than those in whose favor you are 
called upon to interfere. At all events, the well-to-do and 
the rich will gather an advantage from your efforts which 
every one will have a reason to rejoice over. It depends upon 
the certainty that a public sale of the simplest food for infants 
and young children, which at the same time is the very best, 
will always constitute a powerful admonition and instruction 
to the whole community. The facts that infants and children 
do not only bear, but that they require, absolutely plain, 
simple, wholesome, digestible, nutrient food only, only, only ! 
cannot be repeated too often. Let your practical teaching be 
a warning and a blessing by the information extended to the 
public at large ; that the few articles you sell to the poor are 
those which are also best adapted to the rich, and the only 
ones } t ou recommend for the food of the infant and the young 
child of both poor and rich. Nature is too republican in 
spirit, too democratic in character, to bow to differences of 
social standing. 

In this connection I again insist upon a fact which appears 
to be so self-evident as not to deserve mention. And still with 
the utmost pertinacity the public insist upon giving their chil- 
dren, as soon as weaning time arrives, or before that period, 
such articles of food as they know nothing about. When an 
adult sits down to a table, he or she will inquire about a 
strange article of food with which he was not acquainted, 
before. The baby, however, is credulously fed upon things 
which neither baby, nor father or mother, nor doctor is in 
the least informed about. I speak of the baby foods in the 
market, and in general use. Most of these foods, which are 
sold in large quantities, have compositions which are not 
known. When the manufacturer deigns to say anything 
about his merchandise, he assures you that it is the best in 
the market ; that it is the proper thing, the only proper thing, 
for children and invalids of all ages ; that the relation of albu- 
minous substances to carbon hydrates is exactly correct, and 
that a package costs a certain amount of money. In regard 
to this subject the public appear to be smitten with absolute 
12 



178 IMPROVEMENT OF THE CONDITION OF CHILDREN. 

blindness. They insist upon forgetting that the man who 
offers for sale, and advertises at a heavy expense, any article 
of merchandise, does so — as society is constituted — for his 
pecuniary advantage solely. To say that when his article is 
not good it will find no market is deceiving yourself, experi- 
menting on your baby, relying on the character of a single 
man, or a corporation, on the honesty or intelligence of his 
chemist, or his superintendent, or his workmen, on the nature 
and condition of the elements offered for sale, and on a great 
many influences, which can be at work before the manu- 
factured articles get into the hands of the consumer. Why 
the sellers and advertisers of unknown compounds should be 
trusted more than those who raise and sell a simple article of 
food, such as milk, which is constantly adulterated, can hardly 
be perceived. Is it necessary to say that the factory furnace 
works more in the interest of the proprietor than for the benefit 
of the public, and that the examination of many of the foods 
for sale in different packages and in different years yielded 
different chemical and physical results ? 

Meanwhile, it is a fact that no better food can be procured 
than what nature offers with a willing hand, for little work, at 
a trifling expense. There is no food on which infants and 
children of all classes thrive better, thrive so well, as the few 
articles the sale of which, in the manner described, is recom- 
mended to you. In this respect at least, and at this early 
age, there is equality amongst members of society. 

Therefore, no patented article of food should ever be sold 
by you. If, in the Summer Home of the Brooklyn (L. I.) 
Children's Aid Society, they allow every child to continue, 
and every outside practitioner to indicate, its artificial food, it 
is simply a grave mistake, which will certainly be remedied 
as soon as understood to exist. 

Nor do I see that anything could be added to your stock, 
with the exception of brandy. The influence of the summer 
heat is not only destructive by the influence it has on food, 
but also, and mainly, by its debilitating effect on the nervous 
system. It is a physiological fact, always observed and firmly 



IMPROVEMENT OF THE CONDITION OF CHILDREN. 179 

founded on experimental science, that the nervous system of 
little babies is easily overthrown by two entirely different con- 
ditions, both of which are equally" dangerous. The nervous 
system of the newly-born is rather torpid and dull in its 
action, there is very little nervous function ; particularly the 
sensitive portion is but poorly developed. This condition 
depends on the crude and undeveloped state of the brain and 
nervous system, from an anatomical point of view. The nerv- 
ous system of the baby is not yet fully differentiated into its 
later constituents ; it is not mature. Thus a slight influence 
from outside may blow out the light which is burning but 
dimly. On the contrary, after a number of months, the sen- 
sitiveness of the rapidly developing baby's brain and nervous 
system is so great, while the equilibrium between the several 
constituents is not yet established, that a slight disturbance 
will result in irregular reflexes, convulsive movements, and 
death. 

The influence of heat exhausts not only the action of the 
great nerve centres, but also the peripheral nerves, mainly of 
the digestive organs, as well. There are days in which a 
stimulant may safely, and ought to be, given to an apparently 
healthy child. When the baby can be taken from a stifling 
room to a gentle breeze, from the rear of his tenement with 
the exhalations of the sewer and privy to sea-air, or the mount- 
ain, it is not required. But when the hot season is at its 
height, and the baby suffering from it, without an opportu- 
nity to escape it, a few drops of brandy are required. Then 
it is simply a preventive remedy. The clamor of a few 
temperance papers and fanatics over the teaspoonful of brandy 
or whiskey, recommended in the rules distributed by the New 
York Board of Health, has not prevailed upon that authority 
to withdraw the advice, and has not prevented that advice 
from rendering good service. 

I propose therefore that an ounce of either brandy or whis- 
key, per week, be added to the list of your foods for sale, dur- 
ing the four months from the 15th of May to the 15th of Sep- 
tember, provided the weather is as dangerous as it must al- 



180 IMPROVEMENT OF THE CONDITION OF CHILDREN. 

ways be expected at that time. Whether you will conclude 
that the sale of the above article in the afore-mentioned quan- 
tity ought to be controlled by the advice or direction of a phys- 
ician, may perhaps depend on local or personal considerations, 
and must be left to your wisdom. 

The furnishing of proper articles of food, in the manner 
proposed above, will prove health protecting and life saving. 
Still, proper food is but one of the sources of health and life. 
The heat and the atmosphere of a large city destroy many 
infants and children, in spite of appropriate food and tender 
care. Therefore the removal from both is urgently indicated. 
To prevent those who are still well from falling sick, and to 
restore to health those who have been stricken down by the 
heat of the summer, is of equal importance. An attempt 
to fulfill both indications has been made in New York city 
by the steamboat excursions made under the auspices of the 
St John's Guild, for a number of children. Hundreds of chil- 
dren with their mothers are received in the morning on board 
a vessel, on which they are carried into fresh air, and fed on 
wholesome articles of food for some hours. For it is only a 
few hours that the excursion can last. The children have to be 
carried to the landing in the morning through the stifling 
streets, and back through the same in the evening to their 
stifling homes, and must wait on crowded docks before they 
can be admitted on board. It is far from me to detract from 
the good intentions of the guild which surpervises, and the so- 
cieties and individuals who pay for, these attempts at enter- 
taining and saving, but it has always appeared to me that 
the possible good results are disproportionate to the labor and 
expense connected with the excursions. 

There are in the neighborhood of New York two institu- 
tions which may be considered as the types of the attempts 
made up to the present time at either preventing or curing 
the diseases generated by the heat of the large cities. A ref- 
erence to both may be found instructive when the plan of 
establishing a summer sanitarium on a large scale is being 
contemplated. 



IMPROVEMENT OF THE CONDITION OF CHILDREN. 181 

The Summer Home of the New York Children's Aid So- 
ciety at Bath, Long Island, is established for the purpose of 
affording a temporary recreation of one week, or one day, to 
the children mainly of some mission schools. Nothing, in- 
deed, is amiss that is done for the children of any age. But 
the question is permissible whether, — as so little can be done 
at the best by private exertions, and much must be left un- 
done, — the large expense incurred for the recreation and 
pleasure of school children of, at an average, ten or 'twelve 
years, is justifiable, when the same amount of money, and 
the same good will spent on the instantaneous saving from 
imminent death of the many babies who die for want of just 
such a day or week, would be needed more and could be more 
profitably employed. When little can be done, that which is 
absolutely required should be done first. This is not meant 
to include a reproach, however, for a society which, with large 
means, is known to do a great deal of good. Still it is worth 
while to learn what is, and can be, done with the means at 
one's disposal. 

The Annual Report of the Summer Home for 1879 yields 
the following facts : l — 

In the Summer Home — 

915 girls spent each 1 week = 6,405 days. 
268 girls spent each 1 day = 268 days. 
734 boys spent each 1 day = 734 days. 

1,917 Total, 7,407 days, or 1,060 weeks. 

The expenses amounted to $6,387.18 

Of which there were for construction 

and repairs $1,000.00 

For rent, 1878 350.00 1,350.00 

$5,037.18 

No other expenses besides railroad fare are accounted for, 
thus the sustenance of every child for one day costs seventy 

1 Twenty-seventh Annual Report of the Children's Aid Society, New 
York, November, 1879. 



182 IMPROVEMENT OF TEE CONDITION OF CHILDREN. 

cents in food exclusively, plus railroad fare. The expense for 
railroad fares amounts to $739.20, that is ten cents for every 
child every day (leaving nearly sixty cents for food, etc., 
alone) during the whole period, or, calculated for every week, 
eighty cents. This appears enormous, and again the question 
arises, whether the result, a single day's recreation for a girl 
or boy of ten or twelve years, where so very much has to be 
left undone, is not paid — I dare not say too dearly, but — 
dearly for, when the average amount of railroad fare is added 
to the cost of sustenance. 1 And it cannot be proven that a 
single life has been directly saved by either the exertion or the 
expense. 

In this respect the aims and results of the Seaside Home of 
the Brooklyn Children's Aid Society, at Coney Island, 2 are 
quite different. It is no pleasure ground for school children, 
but a home for sick babies, struck down by the heat of the 
summer, and suffering from diseases of the alimentary canal. 
According to the rules, the babies are received on Monday 
morning and remain until Saturday night. Admission is 
granted to sick children of early age, very few being admitted 
over a few years of age, and then only when a sick baby re- 
quires the presence of its mother, who has no other home 
for the rest of her children, upon the certificate of any re- 
spectable ph}'sician of the town, or directly by the superin- 
tendent. Very few remain over Sunday, but admission is 
not restricted to Monday ; any sick baby may be admitted any 
day. Thus it is that the average time a patient remains in 
the institution may be set down at four days, a period amply 
sufficient in most cases to restore the exhausted and dying 
tenement house unfortunates to a possibility of living. Then, 
too, one cannot assert that four days are sufficient in every 
case, but surely they are in the majority. 

1 In a circular directed to the public for the purpose of obtaining con- 
tributions, the number of children " brought down to this resort" from the 
9th of June to the 15th of September is pronounced to have been 2,912, 
and the weekly expense " some two dollars." I have preferred to be guided 
by the figures of the official report, which, however, appears over the name 
of the same gentleman who signs the circular. 

2 Fourteenth Annual Report, November, 1879. 



IMPROVEMENT OF THE CONDITION OF CHILDREN. 183 

And at Avlmt expense ? In 1879, the number of admissions 
amounted, during thirteen weeks, to 

2,423 children, and 
805 mothers. 



3,228 X 4 days = 12,912 days. 

The expenses amounted to $8,331 22 

Of which there were for alterations 

to buildings and furniture . . . $3,748 20 

Building fund 571 04 

4,339 24 



$3,991 98 



These S3, 991. 98 were the expenses for provisions, milk, ice, 
coal, drugs and medicines, horse, wagon, harness, and care, 
express, rent ($125), railroad fares (but $12.34), printing, in- 
surance, salaries and labor ($1,018.15), and sundries, — that 
is thirty-one cents, daily, per head, — well spent on dying 
babies, most of whom would have succumbed but for these 
thirty-one cents, daily spent both humanely and intelligent^. 

Is it possible that a human being should have to perish be- 
cause of the want of thirty-one cents ? 

The influence of heat on disease and mortality is felt 
mainly by children under two years. It is these to whom a 
summer sanitarium which has but limited accommodations 
must mainly be opened. When there is room, older children 
ought to be admitted, up to the age of ten, but the direct life- 
saving influence is principally felt by the children under two. 
The younger they are the more will they be benefited. As 
soon as a mother can leave the bed in which she was confined, 
she may transfer the baby to the sanitarium. When she has 
older children, who cannot be left behind, they must be ad- 
mitted. No delay must be allowed in the cases of those sick 
with diarrhoea. Another night, a few hours in the stifled at- 
mosphere of a hot cit}^, will destroy a life, which may, and of- 
ten is, saved by removal from its danger. In these cases the 



184 IMPROVE ME XT OF THE CONDITION OF CHILDREN. 

removal alone is the remedy. Where it is expected to act as 
a preventive, a few hours, a day, even, may be allowed to 
pass b} T . Those suffering from chronic ailments of nutrition, 
such as scrofula and rachitis, and those affected with chronic 
respiratory diseases, also convalescents from diseases gone 
through at home, ought to be counted amongst those worthy 
of prime consideration. In all of these cases whose sickness is 
the cause of admission, whether it be diarrhoea, chronic bron- 
chitis, or scrofula, age is no longer a consideration, unless the 
patient is beyond or near the limits of childhood. In certain 
classes it is dangerous to allow older children, of twelve or 
more, to mix too fieely with their equals of either sex. Sex- 
ual consciousness is developed so 'early in very many that the 
responsibility in accumulating many, without very strict su- 
pervision, is too great. 

Those who are poor have a good claim to be admitted? 
those who are poor and sick have the best, no matter whether 
the little human being happens to be the offspring of white or 
colored ; Gentile, Jew, or Christian ; wedlock, crime, or love ; 
church-goers or agnostics. A human child not relieved or 
saved where there was a possibility ought to weigh heavily 
on the conscience of society. It is advisable, though, that the 
sanitarium should be large enough to admit such, although 
they may not be absolutely poor, as are entitled to considera- 
tion simply because they are young, and to be preserved and 
saved. The babies of the workingmen who are willing and 
capable of paying must find a better place than a boarding 
house, the prices of which are usually higher than the laboring 
man or small storekeeper can afford to pay. The babies of 
these ought to be admitted on paying the expense of their 
keeping, under the rules and regulations of the general insti- 
tutions. They may be admitted for just the length of time 
which is allowed to the poor, whether the term be three, four, 
or five weeks. 

To benefit a large number, I propose that an admission in 
every case be valid for four weeks. If advisable, a prolonga- 
tion may be granted, or a new admission given. If the child 



IMPROVEMENT OF THE CONDITION OF CHILDREN. 185 

be sick at the end of its term, no discharge must take place. 
Removals against the advice of the institution are out of the 
question. Parents must bind themselves not to remove their 
young without the permission of the officers in charge. This 
rule must be enforced as much as the law of the land allows. 
It permits too much ignorance and cruelty at the best. I 
have seen low-bred, brutal, drunken people, tearing their chil- 
dren from their beds in a hospital ward, take them to what 
they call " home," and deliver them, who had every chance 
to live and get well, to a certain death. These are actual 
cases ; the law permits the innocents to be slaughtered as fam- 
ily property, and the sanitarium must try to counteract the 
lawlessness of inhuman laws by enforcing a certain restriction 
in the indiscriminate and careless removal of their charges be- 
fore the stipulated time. 

The adult accompanying the admitted baby has, besides, 
some office to fill. The mother who comes with the baby or 
babies is naturally bound to perform a certain amount of w T ork 
for them. At home she takes care of the household, cooking, 
washing, sweeping, and attending to the children. In the in- 
stitution she is expected to do the same. While her main 
services belong to her children, these services must be super- 
intended and directed by the large household of which she 
happens to be a temporary member. She has to share in the 
general housework, washing, cooking, and sowing. It is ex- 
pected that cheerful obedience to simple rules and not onerous 
duties will be considered as but a slight recompense for the 
boon conferred upon her and her child. 

The case may occur, though rarely, that a person prove so 
disobedient and unruly as to necessitate her removal. Such 
a case is certainly rare, for those so inclined behave quite well 
when they are in the hands of an orderly community, deprived 
of the injurious influences of coarse example, loose talk, and 
bad drink ; in such a case, when the mother is to be refused 
or expelled, the present laws will permit of the retaining of 
the baby. 

I can hardly conceive of any other reason for removing a 



186 IMPROVEMENT OF THE CONDITION OF CHILDREN. 

child from the sanitarium before the time has elapsed. For 
sickness must be cared for, as it must be expected to happen. 
There will be occasional attacks of diarrhoea, of bronchitis, and 
pneumonia. There will be whooping cough, there may be 
diphtheria, scarlatina, measles, ophthalmia, varicella, even 
variola or varioloid. For the time being, that is, until the in- 
stitution in some future time will be prepared to take charge 
of those already sick, such as are known to be affected with 
any of the above infectious or contagious diseases must not 
be admitted before their complete recovery. But those who 
are taken sick while inmates must find proper care and treat- 
ment in the institution. There must be a separate portion, of 
the same construction and material as the other buildings, at 
safe distances, for whooping-cough, for diphtheria, for measles, 
for scarlatina, for varicella, for varioloid, for ophthalmia. 
There must be rooms for the temporary accommodation of those 
who come in with fever or any other sudden symptoms of a 
sickness not yet fully developed, but of a suspicious character. 
To return them to the city may be required in institutions 
crippled by narrow means and space, but the welfare of the 
patients demands that they should remain where they have an 
infinitely better chance for complete recovery. 

What sort of buildings should be erected for the use of the 
admitted children and their attendants, — brick or wood, large 
or small dormitories, large buildings with small rooms, or large 
dormitories ? One or more stories ? 

It is a mistake to believe that brick buildings are more 
proof against destruction by fire. I have taken some trouble 
to ascertain, as far as the reports were accessible, whether 
more public brick, or wooden, buildings were destroyed by 
fires. It so happens that the larger majority of those so de- 
stroyed were built of brick. For it is not claimed, nor ex- 
pected, that they should be fireproof. 

Nor can it be claimed that plain wooden buildings are 
apt to be easily destroyed by age and wear to such an extent 
as to render their erection and use objectionable. As the 
sanitarium is not expected to be opened for any but the 



IMPROVEMENT OF THE CONDITION OF CHILDREN. 187 

summer season, wooden buildings, to live in, are certainly 
preferable. With but little expense they can be made rain- 
proof and wind-proof, and their proper and complete ven- 
tilation for the purposes for which they are erected offers no 
difficulties, and requires no architectural ingenuity or pecuni- 
ary outlay. Large and solid brick walls, covered with plas- 
tering and wall paper, or oil, or cement, necessitate both ; 
a wooden structure need only be left alone to secure good air 
and sufficient ventilation. Simple clap-boarding, plainly 
painted, does not destroy the necessary spontaneous ventila- 
tion ; large windows and doors admit sufficient light and air. 
Moderately high ceilings, from ten to thirteen feet, accord- 
ing to the size of the rooms, permit the rising of warm and 
foul air, if ever there be any, to a sufficient extent. Plain 
roof ventilation, or a ventilating apparatus near the ceiling, is 
all that I should advise or permit. Open windows, open 
doors, and the spontaneous and constant exchange of air 
through the wooden inclosures are fully satisfactory. As I 
have lived many a year, from four to eight weeks in succes- 
sion, during July and August, in a small frame house, clap- 
boarded outside, and with a plain vertical boarding inside, 
without any inconveniences, and with great advantage to my- 
self and mine, I know that plain and cheap buildings will be 
eminently adapted for your purposes. 

The question as to the general size of dormitories is an im- 
portant one. Large dormitories have the advantage of easy 
superintendence, and some reduction in expense. Thus in 
orphan asylums, and similar institutions for children of ad- 
vanced age, the use of dormitories large enough for a number 
of children has been found appropriate. But the wants of 
very young infants differ from those of the above mentioned 
class. Very few babies, though ever so well, will sleep a whole 
night. Babies will wake up once or twice, and cry. They 
will require the lighting up of the room to have their wants 
attended to. Their attendants will have to get up, walk 
about, and disturb their neighbors, or the whole ward. When 
there are but twenty, or even less, babies in one dormitory 



188 IMPROVEMENT OF THE CONDITION OF CHILDREN. 

there is some disturbance all the time, in the way of noise or 
light. If that be so where all the babies are perfectly well, 
how much more will it be the case when one or more are not 
in perfect health. Amongst a dozen or two babies there are 
always some who are sufficiently disturbed by intestinal 
catarrh, flatulency, or even lesser ailments, although there 
may be no actual disease. Thus the night's rest for all the 
babies and their attendants is more or less interrupted, not 
to speak of the exhalations of excrements, which annoy the 
neighbors as well as the individual baby and attendant. 
This is more than a theoretical speculation ; it is the result 
of actual observation in hospital wards and other institutions. 
Thus I cannot advise the erection of large dormitories for the 
class of infants and children you propose to benefit. The 
houses, large or small, ought to be divided up into small 
rooms. These ought to be large enough to accommodate a 
mother, with all her children, when you will now and then 
find yourself under the necessity of admitting a whole family 
at once. It is perhaps not necessary to allow a separate 
room for a baby and its attendant ; but two, or at the utmost, 
three such parties ought to be the limit. Whether small 
houses be built with a few apartments, or large houses with 
corresponding broad and well lighted corridors to allow of 
freer ventilation and access of light, may appear to be of no 
moment. But as it is not proposed to employ deafening, it 
appears to be more appropriate to build a number of smaller 
houses in preference to a limited number of larger ones. 
The great number of rooms and walls in the latter requires 
so much more material than would large dormitories that the 
diiference in the expense will not be very great. If it were, 
the advantage of separating the inmates, and by separation 
affording them better chances for rest, is so eminent that the 
moderate increase in expense is not worth noticing. The ad- 
visability, however, of separating the babies during the night, 
and in their sleeping hours during the day, does not exclude 
the usefulness and necessity of procuring large halls as a com- 
mon meeting and play-ground for the better part of the day. 



IMPROVEMENT OF THE CONDITION OF CHILDREN. 189 

There, noise and crying or any other mode of their enjoying 
themselves or expressing their wants is rather desirable than 
otherwise. Besides, the presence of all in common rooms se- 
cures the only possibility of close superintendence, as far as the 
cleanliness of the babies, and regularity of feeding hours is 
concerned. This close supervision is necessary both in the 
interest of the little ones, and as a means of discipline for 
the adults, part of whom will always endeavor to benefit their 
individual children, by breaking the rules laid down for the 
whole community, as long as a wholesome habit has not been 
inculcated into them. 

For the reasons given above, I think houses with but one 
story preferable, when the space is sufficient for erecting a 
number of them, with the allowance of enough space between 
each, to secure the free access of air. As, however, the houses 
are but low, the distance between them need not be great. In 
fact, if I allow a surface of one hundred and fifty square feet 
for a baby with its attendant as the size of a bedroom, a dozen 
such collected under one roof would form a house of thirty- 
six by fifty feet, or about two thousand square feet. A dis- 
tance of ten or fifteen feet between two such houses, low as 
they will be, ought to be ample. A row of them ought to be 
connected on one side, with a continuous veranda for increas- 
ing the facility of communication, mainly for the use of the 
superintending nurses and officers. 

The medical service of the sanitarium is of vast importance. 
There will be sickness, and good medical advice ought to be 
procured. It is possible, but not probable, that a superior 
man, and well informed in the physiology and pathology of 
childhood, will or can give four months of every year gratui- 
tously. Such a contingency may be hoped for now and then, 
but cannot be expected. Thus, the physician-in-charge ought 
to be paid for his services. His duty will be to convince him- 
self that the diet of infants and children and adults is just 
what it is meant to be ; to see every room, dormitory, or house, 
and privy once daily, enforce sanitary regulations, and attend 
to every case of sickness. That is serious work, but it can be 



190 IMPROVEMENT OF THE CONDITION OF CHILDREN. 

accomplished with the aid of assistants. These latter must 
be selected from the young physicians, or advanced students, 
who declare their readiness to serve continuously, for board 
and lodging, at least two months — better four. The facility 
for learning in your sanitarium will be so extensive that the 
places will be eagerly sought for. Eight or twelve such assist- 
ants may be required, double the number ought to be bidden 
welcome ; for the institution, while it is meant to benefit the 
infants, can be made serviceable to the improvement of young 
medical men, and through tbem, again, to those whom they 
will have in charge in future. It will be easy to regulate the 
duties of the assistants; the number of infants, children, adults, 
houses, bedrooms, closets and grounds under their charge must 
be determined by their superior officer ; meanwhile, though 
the studies of each man are left to his own selection, a well 
posted physician will do well to treat his assistants as a pro- 
fessor would his students, collect them in a class, discuss gen- 
eral topics connected with the service, and the class of the 
well and sick under their charge, direct their studies in infant 
pathology and therapeutics, see the cases with them at certain 
hours in either a Socratic or didactic manner, and thus pre- 
pare in every season, better than any of our colleges or clinics 
ever yet succeeded in doing, a number of young men for the 
knowledge of, and practice upon, a class of diseases which are 
very frequent, but like sealed books to the young, and many 
an old, practitioner. 

The infants and children remain a number of weeks in the 
institution. The benefits to be derived therefrom are expected 
to be very great for every individual, through the immediate 
effect of the sojourn there. I expect, however, a lasting effect 
also from the sojourn of their attendants and mothers. When 
they leave they ought to be wiser and better. Their weeks 
of staying in the sanitarium must be like a school to them, 
and a source of information. They will gather some informa- 
tion simply from being told what they are to do for the little 
one in the way of dressing, cleaning, and airing, and from 
learning the manner of feeding and the articles of food appro- 



IMPROVEMENT OF THE CONDITION OF CHILDREN. 191 

priate. But more can be done, and easily ; they can be taught 
theoretically besides. I propose that ten or fifteen minutes 
every day should be given to a sort of simple lecture on just 
such topics as are connected with the diet and bringing up of 
children. A woman who stays in the institution a month or 
two ought to take with her, when she leaves it, a stock of 
veiy plain knowledge on a number of points connected with 
the health and sickness of babies : How many passages from 
the bowels are normal, how they ought to look, and what their 
consistency is to be ; how to bathe a child, how to dress it, 
how to keep its feet warm and head cool ; the danger of short 
socks, feather pillows, and woolen head-gear ; how to prepare 
an enema, and apply it ; how to observe the voice of the cry- 
ing child, and judge of the frequency or difficulty of breathing ; 
what to look for in the growing child, — accumulations of filth 
and dead skin on the head, growing mother's marks, increas- 
ing baldness on the occiput, softening of the cranial bones, 
thickening of the long bones ; what to think of the presence 
of, or danger from, worms ; how not to believe in the old 
superstition of dentition being an almost unavoidable danger ; 
and that she is culpably neglectful when not trying to relieve, 
by medical aid, a diarrhoea, or fever, when her child is sick, 
only because her neighbor tells her the child is teething. All 
of these things are very simple, and can be told in simple 
words. Any woman of average intelligence, and with no pre- 
vious schooling, will comprehend and remember them. I know 
that I succeeded in private and dispensary practice in a great 
many instances, and the task will be found very much easier 
when the teaching comes to them in an official manner and 
clad with authority. 

I admit, however, that not every advanced student, or even 
every young practitioner, is conversant with all of the above 
topics to such an extent as to be able to teach them ; but 
their superior medical officer is so, or must be. He can sup- 
ply the knowledge, and when no viva voce teaching is possi- 
ble or advisable, short directions, or lectures, can be provided. 
The purpose in view must be obtained, at all events. If 



192 IMPROVEMENT OF THE CONDITION OF CHILDREN. 

there were none in the whole medical staff who would feel 
capable of teaching the above subjects to the by no means un- 
sophisticated, but mostly slow and plain intellects before them, 
— and there is nothing more difficult than a popular lecture, 
or popular teaching, — a good book ought to be procured and 
read aloud ; if there be none adapted to the purpose, it ought 
to be made. A great deal of common sense and judicious 
knowledge can be condensed in forty or fifty pages, and a 
single page read every day, and discussed ten or fifteen min- 
utes, may be able to change the condition of the poor little 
ones of a large city in a few years by removing ignorance and 
superstition, and breaking the force of bad habits in their 
mothers. When these leave the institution, the babies must 
have laid in a stock of health, and they themselves one of good 
will and some improved knowledge on children and nursing. 

The information gathered by the mothers during their stay 
in the sanitarium I look upon as highly important. They will 
not only be told what to do, but made to do it. The class of 
people from whom your beneficiaries are recruited never learn 
by theory alone, it must be accompanied by practice ; still 
that theory is a necessity for them also, and a blessing, pro- 
vided it be in the right shape : therefore the teaching ought to 
be plain, — what they listen to, intelligible ; what they read, 
clear and brief. It cannot be expected that extensive treat- 
ises on hygiene, or hygienic measures, should be read and di- 
gested by the men and women of the working classes, but 
brief rules will be read and heeded. The effect of the very 
brief rules for feeding babies usually distributed by the New 
York Board of Health goes to prove it. A short tract of a 
page or two, or better one large page, several times a year, 
ought to be carefully worded and widely distributed ; every 
mother ought to be supplied with two or three when she 
leaves the sanitarium. At regular intervals the infant food 
depots, or some other public place, might be made the distrib- 
uting centre of another such tract. One or two topics might 
be treated of at the same time, such, for instance, as have 
been mentioned above. A lithograph, or cheap print of a sub- 



IMPROVEMENT OF THE CONDITION OF CHILDREN. 193 

jeet connected with baby life, could be distributed every 
Christmas, with the main rules concerning feeding, washing, 
airing, and dressing, underneath, on a strong pasteboard, so 
as to secure its indestructibility, and its forming a part of the 
wall ornaments in the residence. 

Such rules, tracts, and pictures could be copied indefinitely. 
They may be kept for sale in the interest of benevolent indi- 
viduals and societies of other cities. It may be that Balti- 
more can thus be made the centre from which every large or 
small city can be induced to obtain its supply of useful, plain 
knowledge on diet, health, and sickness of the young. No 
other city, it appears to me, will have the opportunity of Bal- 
timore, with the magnificent occasion offered by your under- 
taking. The publicity of your work, and its details, and of 
the facilities offered by you, will not be wanting ; for the 
newspapers and journals will have no more interesting or more 
important topic to discuss for a long time. They will also con- 
tribute to diffusing the knowledge you intend to spread, by 
copying your publications, and though but a limited number 
of readers will cut out — as I have seen them doing — just 
such items of domestic and hygienic importance, the notoriety 
given to your plans, and their execution, will create a constant 
demand for the supply of your communications, papers, or 
tracts. Again, they must be brief, not one in a hundred work- 
ing men or women will read an essay, but every one will read 
a page of clear print with home truths. 

Lectures are out of the question ; poor people cannot go, 
and will not. Clergyman, as a class, have no special familiar- 
ity with the topics alluded to, nor would many of them be 
disposed to take an active interest in matters involving merely 
the health of the body. There are, however, some who would 
aid in the development and progress of such a trust as this, 
and appreciate the necessity of now and then giving a thought 
and word to the well being of the future citizen of this 
world. 

Lectures, however, to another part of the community, which 
may be printed or not, will be found of great service. The 

13 



194 IMPROVEMENT OF THE CONDITION OF CHILDREN. 

educated and better situated classes of society will listen, and 
read. Your efforts are mostly directed to benefit the children 
of the poor ; but, even if you meant to, you cannot prevent 
the seed you sow from spreading beyond your own acre. The 
knowledge you spread, the habits you inculcate, the success 
you obtain, will tell their own story. The talk of the people, 
and the discourse of the newspapers, will spread healthy opin- 
ion all over. There is no better teaching than by example, 
which is not only good, but has proved profitable and success- 
ful. But the indirect influence of your efforts need not be 
all; a few lectures every season on subjects connected with 
the questions so dear to you must be delivered in Baltimore, 
by persons whose position and reputation is such that their 
assertions carry weight. These lectures, or some of them, 
ought to be printed and kept for sale. The book trade and 
the news agencies would distribute them by the thousand, by 
the ten thousand ; and while most advantage would be derived 
from them by the publisher, your funds may be benefited by 
the profits obtained. Even though it would be necessary to 
pay the lecturer a fee, it is more than probable in my mind 
that a considerable pecuniary result might be accomplished. 

Thus far I have proposed that what is known to the best 
of the medical profession should, in its results, be communi- 
cated to the public by teaching, tracts, and lectures ; your cor- 
poration may go further, and contribute to the improvement 
of the science of the subject. I advise that a subject be se- 
lected by you, or by a committee of yours, annually or bien- 
nially, belonging to the domain of diet, physiology, and pa- 
thology of infancy or childhood, and that a prize should be 
established for the best competing paper on the subject. No 
money ought to be paid for the best effort. A medal gained 
for scientific honors from your body will fully pay the crowned 
winner. It is not at all necessary, or advisable, that the 
question proposed should be taken from the domain of diet 
alone ; on the contrary, it is rather advisable to select a prob- 
lem out of the many which are still waiting for their solution. 
America has not contributed very much to psediatric science. 



IMPROVEMENT OF THE CONDITION OF CHILDREN. 195 

I hope it is you who will succeed in creating the taste for it, 
and usher in a most needed progress. 

To provide the poor infants and children of a large city with 
wholesome food, and to establish a summer sanitarium for 
the prevention and cure of the diseases depending on heated 
arnd contaminated air is an undertaking of vast importance, 
and in itself a great blessing, such as no other corporation in 
any community ever had an opportunity of conveying to the 
same extent. The thoughtful benevolence of Thomas Wilson, 
however, and the careful preparations being made by your 
board for the execution of his will and the administration of 
his bequest, encourage me in putting in a further plea in be- 
half of the poor and sick infants and children. It is true that 
even large means do not suffice for all purposes, but these 
purposes must be first stated to be generally understood, and 
aims must be pointed out first before the efforts can be made 
to reach them. It has often appeared to me that misery is so 
great and universal only to enlist greater and more universal 
sympathy, pity, and humane efforts to relieve and remove it. 
The historical development of mankind which led to poverty, 
sickness, and sin has also evolved wealth, knowledge, and 
humanitarian enthusiasm. The race of the Hopkinses and 
Wilsons cannot be, and is not, extinct. If the means at your 
disposal be not sufficient to accomplish all that is required, I 
trust that they will be increased by well-directed benevolence 
of citizens equally blessed with great riches and great souls. 

My plea is for the establishment of children's hospitals. It 
is true that there is hardly a general hospital in which sick chil- 
dren are not met with. They are mostly chronic cases, bone 
diseases, malformations, and disorders of nutrition. For reasons 
connected with the general discipline of a hospital, and the 
difficulty of procuring fresh air to a sufficient extent, the lat- 
ter class are seldom benefited. The first class, also, are but 
rarely benefited, unless they be of recent origin. If there be 
any class of diseases dangerous to other patients, and not 
improved themselves, and which requires special accommoda- 
tions of their own, it is that of chronic bone diseases. All of 



196 IMPROVEMENT OF THE CONDITION OF CHILDREN. 

these children are, as a rule, kept in the wards of adults, there 
to be cared for partly by the nurses, and partly by the con- 
valescent patients. This usage is of little advantage to the 
sick, while it may prove an annoyance, and detrimental to the 
class of legitimate inmates. Besides, the association of older 
children with most of the inmates of a hospital is not an ad- 
visable one. The moral tone of the wards is mostly not very 
elevated, and it is a wrong to expose the children — subject 
already to so much doubtful home and street influences — to 
moral contamination in order to obtain a rather uncertain 
physical benefit. 

Infants, who are so much more liable to be taken with acute 
and life-endangering maladies than the class we generally 
meet with in hospitals, are not admitted. Thus, those who 
require most aid receive none. 

To obviate the incongruities and disadvantages of placing 
infants and children in the same wards with adults, in some 
hospitals a special ward has been reserved for children ; but 
by so doing, the administration of an institution being of ne- 
cessity, uniform, no justice is done to the wards of the young, 
as I shall say later. The classes of diseases are so various, 
the number of contagious affections so great, the propagation 
and multiplication of disease in a single ward or two, with no 
possibility of removal or isolation, so palpable, that this ar- 
rangement has been found to be dangerous in many cases, 
though in a number of instances it proves serviceable. Con- 
tagious eye and eruptive diseases are often multiplied in a 
child's ward. 

One of the reasons why the number of children's hospitals 
is still so limited in most countries, and mainly in ours, may 
be found in the fact that the needs and wants of an institu- 
tion designed for the care of sick infants and children are very 
much more complicated than of those for the reception of 
adults. The difficulties alluded to are so serious that there 
are so-called children's hospitals which will receive no patients 
at less than five years. On the other hand, those who under- 
stand their duty, and mean to do it, take the responsibility 



IMPROVEMENT OF THE CONDITION OF CHILDREN. 197 

when it offers itself. Thus the child's hospitals of St. Peters- 
burg, Vienna, Stettin, Basle, Berne, and Frankfort have a 
percentage of from eight to twenty-seven per cent, of inmates 
under a year, and of from thirty to fifty per cent, under three 
years. The children's ward of the Mount Sinai Hospital, New 
York, never asks for the age of the patient before deciding on 
the propriety of admission. 

Amongst the difficulties to overcome in a child's hospital is 
the necessity of procuring an increased number of nurses. The 
mortality of children is greater than that of adults, their dis- 
eases mostly more changeable, their personal wants must all 
be attended to by others. Thus the number of nurses is to 
be larger than for the same number of beds in a general hos- 
pital for adults ; and the training of the nurses, if anything, 
more careful. The wards must be smaller, for the patients 
are more apt to disturb each other; therefore not too large a 
number must be congregated in one ward. The largest ward 
of a large child's hospital ought not to have more than 
from fourteen to twenty beds, part of which ought to con- 
tain convalescents. The number of smaller rooms must be 
greater ; they must be so arranged as to be capable of com- 
plete isolation, when this is required, along a light and airy 
hall. The cubic space reserved for each child must be at least 
as great as that for adults, for their respiration is very active ; 
their evacuations are in part passed into the beds or linen, or 
at all events inside the sick-room, and a larger staff of attend- 
ants and nurses is present in addition to the patients them- 
selves. Not only a sufficient cubic space, perhaps of 1,500 
cubic feet, is required ; it is perhaps of still greater import- 
ance that the distance of the beds from each other, and from 
the walls and windows, be made ample, in the interest of com- 
fort, and of nursing and attending. More of these minutiae, 
however, come into consideration when the building of a hos- 
pital is actually contemplated. My object was only to show 
that the difficulties in the way of a child's hospital are rather 
greater than those met in general hospitals, and thereby, cer- 
tainly not to discourage the undertaking, but to secure com- 



193 IMPROVEMENT OE THE CONDITION OF CHILDREN. 

plete and perfect preparations. We have done but little in 
our country for the benefit of sick children, as far as hospitals 
are concerned. In fact, there scarcely are any, if those insti- 
tutions are excepted, which, under the name of nurseries, suc- 
ceed in so keeping and nursing their little inmates, that those 
admitted in health are soon taken sick, and those taken sick 
die ; this is by no means an exaggeration. If there were a close 
superintendence on the part of the authorities over the many 
so-called private institutions for which cities and states pay 
largely with the understanding that they never look into the 
manner in which their money is spent, they would be sur- 
prised at the death-rate of the inmates. When ten years ago 
I proved that a large institution in Xew York city spared al- 
most none, literally, of its many babies, I was requested to 
resign my position, and, when I insisted upon publicity, ex- 
pelled, and the very next annual report exhibited the fact, 
that the admissions of children not born in the institution 
were almost exclusively of those near or over two years, when 
both danger and mortality are naturally lessened. 

Many countries have clone more than ourselves; none, how- 
ever, enough ; still there are a few European cities which 
have accomplished a certain result in procuring accommoda- 
tions for their sick babies and children. 

The following table has been taken from Rauchfuss, in 
Gerhardt's Handbuch der Kinder Krankheiten, i. p. 419. 







■r. . 


— ■ a 


Tor every 10,000 Inhab- 






b£? 


.£ *** 


itants at the rate of 




a. Beds. 




Is 












r: =. 












« * 


~' £ 


a. 


6. 


c. 


London 


310 


2,500 


60,000 


1.4 


7 


170 


Liverpool 


SO 


4S4 


8,000 


1.5 


9 


150 


Vienna 


300 


2,000 


25,000 


3.5 


23 


300 


Manchester 


210 


- 


14,250 


4 


- 


300 


Prague 


92 


1,180 


7,220 


5 


60 


360 


Moscow 


280 


- 


- 


7 


- 


- 


Paris 


1,100 


7.100 


35,000 


6.5 


3S 


200 


St. Petersburg .... 


470 


3,000 


30.000 


7 


42 


420 


Lisbon 


160 


- 


- 


/ 


- 


- 


Stettin 


56 


2S0 


1,000 


7.3 


37 


130 


Basle 


60 


230 


232 


12 


50 


50 



IMPROVEMENT OF THE CONDITION OF CHILDREN. 199 

It contains the number of beds in children's hospitals, the 
annual number of patients, and patients of dispensaries. 

In Dr. Rauchfuss' opinion the highest above figures are still 
to be considered as minima ; ten beds with seventy annual 
patients, and five hundred dispensary patients to ten thousand 
inhabitants, will not be found to surpass the needs of the com- 
munity. 

Dispensaries for the children of the poor are a necessity as 
well as hospitals. Many cases of sickness require no hospital 
treatment, and no superior knowledge of nursing, such as a 
well-kept hospital can alone suppty. Slight ailments which, 
when either not understood or neglected, become great evils ; 
malformations which can be remedied by an occasional dress- 
ing, or manipulation, or operation, at longer or shorter inter- 
vals ; chronic ailments which require the same or similar 
medicinal treatment, besides advice in regard to diet and nurs- 
ing; many an acute case even which will run a favorable and 
smoother course, when once guided and directed, — all these 
numerous cases are sufficiently benefited by dispensary treat- 
ment. 

The opportunities of a dispensary are two fold: it acts as a 
healing institution, and prevents, by its easy accessibility, 
many a trifling complaint from becoming a serious malady. 
It affords medical advice and medicine. In some Paris dis- 
pensaries baths are given besides. The out-door department 
of the Prince Oldenburg Child's Hospital in St. Petersburg 
has moreover a room to rest in for those who come from great 
distances. Its second great opportunity consists in its ability 
to prevent disease by sound advice given. It is a fit place to 
teach simple lessons, to distribute brief tracts on hygienic sub- 
jects. 

There is a serious drawback, however: the child needing 
advice and going to obtain it, in a dispensary, is necessarily 
exposed to the air ; many a sickness may be, and has been, 
rendered severe by such exposure to all kinds of weather. 
The time spent in waiting before the individual patient's turn 
comes is a serious infliction upon its comfort, temper, and some- 



200 IMPROVEMENT OF THE CONDITION OF CHILDREN. 

times health. It is, while waiting, exposed to the possibly 
contagious diseases, wittingty or unwittingly brought to the 
same place, for this is a possibility which cannot be altogether 
avoided, though some large dispensaries in Europe have a 
place in which a cursory preliminary examination concern- 
ing contagious diseases is made before the patient is admitted 
to the general waiting room. 

It is, however, not only the sick child who may be injured 
bj being taken to a dispensary ; as it is liable to be endan- 
gered by others, so are others by it. The danger of spreading 
contagious diseases is enhanced by the indiscriminate trans- 
port in public vehicles, which cannot be prevented. Thus, 
whatever is done, is not always for the best — as in all human 
things. Nor can such danger always be avoided. Possibly 
the establishment of several small dispensaries in place of a 
single large one, and greater facilities for the treatment of 
sick children at home, and the procuring of more extensive 
hospital arrangements, are amongst the improvements and 
blessings to be wished for. 

At all events, as the danger of communicating diseases is so 
very great, it is advisable not to have the dispensary depart- 
ment, although it may be connected in its administration 
with a hospital, under the same roof. If barely possible it 
ought to be in a separate building, and care taken tha^t no 
communication takes place between the two. No nurse of one 
ought to attend in the other. 

There can be but one connection, which is this : the out- 
door department is necessarily the feeder of a hospital ; cases 
too severe to be treated at home under unfavorable circum- 
stances or such as would be injured by letting them return 
home, must be admitted to the hospital immediately. 

Both hospitals and dispensaries wield a wider influence, 
however, than through their immediate effect only upon those 
whom they directly influence. Their mediate blessings are at 
least as great, perhaps greater, for the greatest boon to infants 
and children is the increased number of physicians who are 
intimately acquainted with their nature and ailments. The 



IMPROVEMENT OF THE CONDITION OF CHILDREN. 201 

field of observation in large institutions is so great, and the 
opportunities for learning so extensive, that the medical men 
connected with special establishments of the kind cannot but 
progress rapidly in the knowledge of the topics connected with 
that special branch of practice. It is only the half educated, 
or poorly gifted of them, who would be induced to look upon 
the practice in children as a specialty. In fact, the tendency 
of running off into unjustifiable specialties to such a degree 
as is done in our country and in a few centres of Europe, for 
instance in Vienna, is but the outgrowth of insufficient gen- 
eral education or mercenary motives. The really educated 
and intellectual physicians would avail themselves of their 
opportunities for the benefit of their charges and their peers ; 
for it is to them that the profession would, and has to look for 
for further instruction and progress. Their assistants and 
clinical pupils — for I take it for granted that the advantages 
of observation would not be lost, no matter whether the hos- 
pital and dispensary were closely connected with Hopkins 
University or not — would learn directly, participate in their 
observations, study their method, and go out well prepared 
for the strife with disease. Their clinical lectures, their pa- 
pers in medical journals, their publications in the annual re- 
ports would not only contribute directly to the stock of 
knowledge of medical men, but — and that is of vastly greater 
importance yet — create a widespread interest in the physiol- 
ogy and pathology of childhood. That it is necessary to still 
create such an interest is a remarkably sad fact, but such it is. 
Not one of the colleges of the United States twenty years ago 
but had a " chair for obstetrics and the diseases of women and 
children," — not one, not a single one of them, which ever 
taught diseases of children either theoretically or practically. 
The first clinic for diseases of children — a poor single hour 
every week — was established in the New York Medical Col- 
lege. When this closed its doors, the clinic was transferred 
to the University Medical College, it still being the only one 
in existence. During the last ten years, a few of the larger 
colleges of the country have imitated that example, but with- 



202 IMPROVEMENT OF TEE CONDITION OF CHILDREN. 

out admitting the teacher of diseases of children to the ac- 
knowledged position of a member of the faculty : and without 
making the study of the diseases of children compulsory on 
the part of the students, without subjecting them to an exam- 
ination on that subject before the}^are given a diploma, which 
gives them a right to go out into the world to destroy or spare 
— as fate wills it — their neighbors' young offspring. And all 
the time the teacher of obstetrics calls himself also the profes- 
sor of the diseases of women, and the professor of obstetrics 
and diseases of women calls himself, also, professor of the dis- 
eases of children. Thus it is not only that the study of the 
diseases of children has been neglected, but that a young stu- 
dent is led to think of it as a rather superfluous task. Be- 
sides, babies and children in practice are easy to deal with, for 
they cannot resent ill treatment, claim damages, or impair the 
good doctor's reputation by complaining. 

All that may be changed by you, in Baltimore, and beyond 
the city's limits. For while a bad example is contagious, a 
good one is fortunately, at least, just as much so. I feel that 
a single earnest attempt is all that is required. When it is 
made at Baltimore, with its just expectation of becoming the 
centre of learning, and particularly medical learning, in the 
United States, it will be doubly effective. 

The hospitals for sick children, and hospitals in general, are 
necessarily limited in their means, the space they occupy, and 
the accommodations for beds which they offer. A large city 
ought to have, therefore, in proportion to its population, sev- 
eral institutions for rather different purposes. An institution 
for the relief of acute inflammatory diseases, while located as 
healthily as possible, must necessarily be at no unreasonable 
distance from the homes of the sick ; for transport to a dis- 
tance is, of necessity, attended with dangerous consequences ; 
many a patient dies of it. 

On the other hand, places destined for the relief and cure 
of chronic ailments, such as rhachitis, scrofula, bone diseases, 
ought to be established at a greater distance from the cities, 
on mountains, or the sea-shore ; chronic pulmonary diseases 



IMPROVEMENT OF THE CONDITION OF CHILDREN 203 

require plateaus protected from changing winds and temper- 
atures. 

Professor G. Barellaj, of Florence, Italy, founded the first 
sea-shore hospital for chronic ailments in Viareggio ; and in 
1873 as many as eighteen existed in Italy, that were founded 
on the same plan. Count Ricardi de Nestro established, in 
Turin, a hospital for rhachitic children in 1872. Within a 
year, two additional ones were called into existence. Moral 
contagion is not always detrimental in character. In Milan, 
Dr. Pini founded a similar institution. The hospital for 
scrofulous, rhachitic, and anaemic children, in Berck-sur-Mer, 
admitted, between the years 1861 and 1865, 380 children, of 
whom 234 recovered, 93 were improved, 35 were not im- 
proved, and 18 died. The stations at Venice, Rimini, Seotri, 
and Fano, had 1,359 recoveries, and 758 partial recoveries, 
out of 2,283 admissions. The establishment of Oranienbaum, 
near St. Petersburg, Russia, admitted 217 children at an av- 
erage age of nine years, of whom 96 are reported as recov- 
ered, 95 as improved, 20 as not improved, 5 as worse, and 1 
dead. These percentages of entire recoveries in a class of 
cases which, under ordinary circumstances, give rise to pro- 
tracted illness and lingering are so satisfactory, that the very 
mentioning of them ought to be enough to enlist the warmest 
sympathy in behalf of a class of children who, while suffering 
from the curse of inherited poverty and acquired ill health, 
might be readily aided by the benevolent efforts of wealthy 
individuals, — or the collective means of society. They are 
the very class who, when they grow up with their ailments 
and incapability to produce, will, through the course of their 
lives, consume the marrow of the land in hospitals, refuges, 
almshouses, and penitentiaries. 

A large number of children, and very often healthy and vig- 
orous ones, are destroyed yearly by infectious and contagious 
diseases. Municipal consciences have been awakened some- 
times to the knowledge of that fact, and endeavored to guard 
against it by closing school rooms in the faces of children com- 
ing from infected houses. This is a necessity from the point 



204 IMPROVEMENT OF THE CONDITION OF CHILDREN. 

of view of protection to the well. From that point of view it 
is even explainable and justifiable that the whole population 
of a tenement house, in which a single case of communicable 
disease happens to exist, is driven back to its dens ; all of this 
is just and proper on the part of those who do not yet suffer, 
but is it just and humane when considered in the interest 
of those locked up in their pestiferous atmosphere ? Or does 
this very process of locking up yield any favorable results ? 

By no means ; for the fact is undoubted that from one or 
more such infected localities the epidemic will spread ; it is 
apt to spread in the same degree that the population is densely 
concentrated around the infected locality. That is natural 
enough, for the disease will spread where it took hold, the 
number of cases will increase, the character of the epidemic 
become graver. If the first case could have been removed, 
isolated, and taken care of, the malady might have been 
stopped, lives and means been saved, and the community 
effectually protected. 

Now, general hospitals do not admit contagious diseases, 
though some of them, for instance, the Victoria Hospital, 
London, England, have fever wards for the admission of that 
class of cases; there is always one or the other communicable 
affection which is not allowed to enter ; thus, for instance, 
small-pox. The majority of hospitals remove from their wards 
even such as are taken with contagious diseases while inmates 
of the same. There are but few, and particularly but few 
children's hospitals in existence which have the opportunity 
of isolating those who are taken sick so as to require separa- 
tion. Such are the St. Wladimir of Moscow ; Nicolai, Elisa- 
beth, and Peter Von Oldenburg, of St. Petersburg, or the 
Child's Hospital of Basle (Switzerland), or Lisbon, the Eve- 
lina Hospital of London, and also some others, to a certain 
extent Vienna, Prague, and Stettin. 

If there were hospitals enough with sufficient accommoda- 
tions for the isolation of those who are taken with a contagious 
disease after having been admitted for other reasons, and 
other hospitals established for the acknowledged purpose of 



IMPROVEMENT OF TEE CONDITION OF CHILDREN. 205 

receiving at once those taken with communicable affections 
in their residences, these homes crowded with children and 
adults would be protected and saved, and many a fatal epi- 
demic stamped out at the beginning. The unnecessary and 
preventable waste of life is fearful, and if the waste of prop- 
erty annihilated by preventable disease and death was counted, 
or could be estimated, — with the loss in material, money, 
labor, time, health, and comfort, — the political economist 
would be surprised. 

It is not too earty, then, to emphasize the necessity of es- 
tablishing hospitals for the reception and treatment of con- 
tagious diseases. They are required in the interest of those 
taken, and those who are still well and almost certain to be 
taken. In regard to small-pox, some communities enforce the 
rule of isolation even against those who are unwilling, in the 
interest of the whole community. Small-pox, however, as we 
meet it, in both sporadic cases and epidemics, and modified by 
vaccination, is by no means the most dangerous scourge ; 
many an epidemic of diphtheria and scarlet fever has proved 
more fatal than varioloid. Special hospitals are a necessity, 
and public opinion will not always be satisfied with halfway 
measures. The progress of human development will insist 
upon the necessity of greater protection for the community, 
and better accommodations for those who suffer from the 
most dangerous forms of sickness. Besides, humane thought 
and sympathy will readily be enlisted in behalf of those who, 
while suffering most seriously and most frequently, are most 
helpless ; for childhood is the harvest-field for the murderous 
epidemics. The man who, in any town of the globe, will sac- 
rifice part of his wealth for the erection of a hospital destined 
for the exclusive reception of children suffering from conta- 
gious diseases, is sure to make his name a blessed household 
word, and crown his head with immortal glory. 



OBSERVATIONS UPON THE SANITARY CARE 
AND TREATMENT OF CHILDREN AND THEIR 
DISEASES. 

In Answer to certain Questions propounded by the Trustees of The 
Thomas Wilson Sanitarium for Children of Baltimore City. 

y 

BY J. FORSYTH MEIGS, M. D., 

Member of ike College of Physicians of Philadelphia, one of the Physicians 
to the Pennsylvania Hospital, etc., etc. 

The trustees of " The Thomas Wilson Sanitarium for Chil- 
dren of Baltimore City " having requested me to prepare an 
essay on certain matters connected with the establishment 
of this institution, I proceed to fulfil this request to the 
best of my ability. The trustees desire information, first, as 
to " the best method of establishing a Sanitarium (not a 
hospital but a summer retreat) for sick children, under the 
most favorable hygienic and local conditions that the neigh- 
borhood of Baltimore may afford." They state that " the 
land lying north and west of the city is high and picturesque, 
and elevations of four hundred feet above tide are reached by 
steam railway in thirty minutes, and those of six hundred to 
eight hundred feet in an hour. These districts have always 
been healthy - — the water is pure, and food of all kinds is 
plenty and cheap. The ocean is not within available dis- 
tance, and the shores of the Chesapeake Bay are malarial." 

In regard to the choice of the site for the institution, I may 
say that my experience in the diseases of children in Philadel- 
phia has led me to think on the whole, that an interior region of 
some altitude above the sea is preferable to the sea-side. The 
healthiest localities near Philadelphia are those situated from 
four hundred to five hundred feet above tide and away from 
the lower river- valleys. Sites which drain rapidly into swiftly 



SANITARY CARE AND TREATMENT OF CHILDREN 207 

running streams, so that the surface shall be dry, are the best. 
A rolling country is for the same reason better than a flat 
one. The soil ought to be gravelly or porous, and at the same 
time reasonably fertile, in order that it may yield good grazing 
fields for the animals which must supply one of the main foods, 
milk, for the inmates of the establishment. There ought to 
be some large and open woods on the grounds, to afford shade 
in hot weather, both for the children and for the animals, and, 
if possible, the soil should be of such character as to afford a 
rich soft grass beneath the trees. 

For the site of the buildings, I recommend the highest point 
on the ground selected for the farm, in order that these may 
be exposed to all the summer breezes. As the institution is 
intended for use in the hot months of the year, an expos- 
ure of this kind will be altogether advantageous. Were they 
to be used in the winter season, also, such a situation might be 
objectionable, but, as the summer diseases of young children 
are largely the result of high temperatures, it should seem 
that the cooler the buildings can be kept in the heated term of 
the year, the better for the inmates. 

The trustees state that elevations of four hundred feet above 
tide can be reached by railway from Baltimore in thirty min- 
utes, and those of six hundred to eight hundred feet in one 
hour. It appears to me that the elevations of six hundred to 
eight hundred feet would be greatly preferable to those of 
four hundred feet. If, therefore, the distance does not raise 
the cost of transportation too high for the funds of the san- 
itarium, the higher altitudes are those I should recommend. 
The temperature falls decidedly as the elevation rises, and 
this single consideration ought v to decide the trustees to select 
the higher points if they are at all attainable. 

In order to assist the trustees in their choice of the site for 
the institution, I will quote a few of the rules laid down by Dr. 
Edmund A. Parkes, in his "Manual of Practical Hygiene in- 
tended especially for Medical Officers of the Army [of Eng- 
land] and for Civil Medical Officers of Health," fourth edition, 
London, 1873, upon the relative value of localities and soils 



208 SANITARY CARE AND TREATMENT OF CHILDREN. 

for military encampments. He states that " as a rule, it is 
considered that loose porous soils are healthy, because they are 
dry, and with the qualification that the soil shall not furnish 
noxious effluvia from animal or vegetable impregnation, the 
rule appears to be correct." He also states that " gravels of 
any depth are always healthy, except when they are much be- 
low the general surface, and water rises through them; gravel 
hillocks are the healthiest of all sites, and the water, which 
often flows out in springs near the base, being held up by 
underlying clay, is very pure." 

He remarks that " among hills, the unhealthy spots are 
inclosed valleys, punchbowls, any spot where the air must 
stagnate, ravines, or places at the head or entrance of ra- 
vines." . ..." A saddle-back is usually healthy, if not too 
much exposed ; so are positions near the top of a slope." — 
On plains the most dangerous points are generally at the foot 
of hills, especially in the tropics, where the water, stored up 
in the hills, and flowing to the plain, causes an exuberant 
vegetation at the border of the hills." " Herbage is always 
healthy. In the tropics it cools the ground, both by obstruct- 
ing the sun's rays, and by aiding evaporation ; and nothing is 
more desirable than to cover, if it be possible, the sandy plains 
of the tropics with close-cut grass." Speaking of trees, he 
says, " Trees should be removed with judgment. In cold 
countries they shelter from cold winds ; in hot, they cool the 
ground ; in both, they may protect from malarial currents. A 
decided and pernicious interference with the movement of the 
air should be almost the only reason for removing them. In 
some of the hottest countries of the world, as in Southern 
Burmah, the inhabitants place their houses under trees with 
the best effects ; and it was a rule with the Romans to encamp 
their men under trees in all hot countries." 

In his directions for the preparation of a site for military 
purposes, he gives the following summary of rules for improv- 
ing the healthiness of a site. 

" (1.) Drain subsoil, and lower the level of the ground water. 

" (2.) Pave under houses, so as to prevent the air from ris- 
ing from the ground. 



SANITARY CARE AND TREATMENT OF CHILDREN. 209 

" (3.) Pave or cover with short grass all the ground near 
buildings in malarial districts. 

o 

" (4.) Keep the soil from the penetration of impurities of 
all kinds by proper arrangements for carrying away rain, sur- 
face and house-water, and house impurities." 

The supply of water at the Baltimore sanitarium will con- 
stitute one of the points most important to be considered in 
the choice of a site. To secure, if possible, one or more springs 
of pure water within the grounds would be a great desidera- 
tum. A stream of pure, good water running swiftly through 
the farm would be invaluable, whether for the supply of drink- 
ing-water, water for cooking, washing, and bathing, or for the 
coolness it imparts to the air. The amount of water ought to 
be large, in order that it may be supplied by water-wheels, 
windmills, or rams, to all parts of the buildings. Whether 
such a stream could be used, after all the water needed for the 
buildings had been taken from it, for the purposes of drainage, 
would depend upon its volume and force, and upon the dis- 
tance from the buildings at which the drain or sewer might be 
led into it. 

The trustees request suggestions as to the " character of the 
buildings that may be requisite ; their grouping or isolation ; 
how best to provide for mothers or tmrses accompanying their 
children." 

I know little myself in regard to the details of buildings 
intended for these purposes. I applied therefore to Dr. F. W. 
Lewis, of this city, for information on these points. Dr. 
Lewis has been one of the managers of the Children's Hospi- 
tal of Philadelphia since its foundation, and has always taken 
an active interest in it. He was also one of the original man- 
agers of the " Sea-Shore House for Invalid Children" at At- 
lantic City. His experience has been large and recent, and 
he allows me to lay before the trustees some of the opinions 
he has formed upon these points. 

He says, " in the first place I would, for various reasons 
(but especially for the difficulty in the way of proper super- 
vision, etc.) object to the system of small detached buildings 

14 



210 SANITARY CARE AND TREATMENT OF CHILDREN. 

(cottage hospitals so called), except in the case of nursing in- 
fants, whose mothers also require change, and of children af- 
fected with loathsome or offensive discharges ; and even for 
these it would seem preferable to have small (creche) wards 
immediately adjoining the nurses' quarters in a large hospital 
building." He proposes a centre building with a long ward 
on either side. In the centre building he would place the 
rooms for the administrative offices, and at the point where 
the wings spring from the centre, the nurses' quarters. In the 
same building, and next to the nurses' quarters, he proposes 
two small wards, that on one side for nursing women and 
their children, and that on the other for cases of loathsome 
or offensive discharges. The two small wards, for these pur- 
poses, should communicate with the nurses' quarters, but 
should be separated by the nurses' rooms from the long wards. 
In the rear of the centre building he proposes to place the 
kitchen, laundry, etc., communicating by a covered passage- 
way. There should be additional small rooms, he thinks, ad- 
joining the wards, with arrangements for cooking broths, etc. 
At the outer ends of the two long wards should be placed the 
water-closets and bath-rooms, separately ventilated, i 

This arrangement can be made for either one or two stories, 
and, in either case, the roof is simply an ornamented air- 
chamber aiding in the ventilation. Piazzas should, of course, 
surround the wards, on the lower story at least. " The de- 
tails," he adds, " could be infinitely varied to suit the nature 
of cases received." 

At the House for Invalid Children at Atlantic City, they 
have adopted a system for nursing children whose mothers 
are obliged to accompany their infants, or who themselves 
need change of air, of small, detached, one-story cottages 
(without cellars of course), built of wood, with one window 
and door. Each cottage cost about $150. About twelve 
have been erected between the main building and the sea- 
beach. Mothers and infants are received for a fortnight or 
more. Dr. Bennett, the physician in charge, informs Dr. 
Lewis that the plan has worked admirably, although, at first 



SANITARY CARE AND TREATMENT OF CHILDREN 211 

sight, these structures might seem difficult to keep dry in wet 
or stormy weather. 

Dr. Lewis further suggests, that for an " institution to re- 
main open for the summer months only, and designed as a 
convalescent hospital, the following seem to me to be the offi- 
cers and help required, say for ninety children : — 

" (1.) A resident physician. 

" (2.) A steward. 

" (3.) A matron. 

" (4.) Fifteen nurses, or one to every six children. This is 
about the proportion at the Children's Hospital, and, where 
infants and very young children are received, it is none too 
large. A night nurse is included in the number. 

" (5.) Two cooks (head and assistant). Three laundry 
maids, and such male help as the hospital grounds may re- 
quire (say three). 

" This, I must admit, appears a very large force of officers 
and help for only ninety children (twenty-six officers, that is, 
in all), but I do not see how the number could be lessened 
without prejudice to the efficiency and completeness of the 
hospital." 

" I roughly figure," he goes on to say, " the entire cost of 
such an establishment, with such a corps of officers, nurses, 
etc., at about $16,000 per annum. This estimate is based on 
the following figures, derived from the annual reports of the 
Children's Hospital for the year 1877 and for 1879 : " — 

1877. 

Cost of a child per day, including food, wages, fuel, and 

medicines ........ 38^j- cents. 

Cost of a child per day, for food only . . . 25||- cents. 
Cost of a child per day, including all expenditures . 54 cents. 

1879. 

Cost of a child per day, including food, wages, fuel, and 

medicines ........ 38 T V cents. 

Cost of a child per day, for food only . . . 18 T 2 T cents. 
Cost of a child per day, including total expenditure . 54|f cents. 



212 SANITARY CARE AND TREATMENT OF CHILDREN. 

He adds that the Children's Hospital total expenditure in- 
cludes a large dispensary, providing free advice and medicines 
(some surgical instruments, appliances, also) for nearly eight 
thousand cases (not visits) annually, so that the estimate 
should be relatively less in a hospital not having this adjunct. 
Making a reasonable deduction for this, the cost would per- 
haps be about fifty cents, or even less, per child in the total 
expenditure. 

The trustees, again, desire information as to " regulations 
for receiving and administering medically and otherwise to 
the proper object of their care." 

Upon this point I will remark that I have been informed, 
by a gentleman connected with the dispensary attached to 
the Children's Hospital of Philadelphia, that the women who 
bring their young children to the dispensary for treatment 
are very unwilling, as a rule, to place their children in the 
hospital. When advised to do so by the prescriber they not 
only refuse, but often do not return for further advice. How 
this difficulty is to be met by the Baltimore sanitarium I do 
not see, unless arrangements can be made for taking, in some 
cases at least, the mothers with the children. 

The institution will be obliged, in the instance of nursing 
children, to provide accommodations for both mother and 
child, since to wean a child at such a period would greatly 
increase the danger to life. Another difficulty in such cases, 
connected with the removal of the mother from the city with 
her ill child, will be the question, what is to become of her 
other children, if she have any ; who is to take care of them, 
should she have no relation nor friend to take her place in the 
family during her absence ? I will suggest that the sanita- 
rium have in its employment several elderly, respectable 
women, or nurses, stationed in the city, who might, for mod- 
erate compensation in urgent cases requiring immediate re- 
moval from the city, take the place of the mother in the care 
of the household during her absence. Of course such a sys- 
tem would need great care in the selection of the agents, but 
I do not think of any other plan to meet this difficulty. It 



SANITARY CARE AND TREATMENT OF CHILDREN 2l3 

would be expensive, but it would solve what otherwise ap- 
pears to me a great obstacle to the full success of the sani- 
tarium. 

The sanitarium ought to have attached to its central office 
in Baltimore one or more competent physicians, whose duty- 
it would be to see at the office, or visit at the houses of the 
applicants, the children for whom relief is sought. The phy- 
sician or physicians selected for this duty ought to be men 
of some considerable experience, in order that they may be 
skilled to detect contagious diseases in the proposed patient. 
In doubtful cases, the authorities at the sanitarium should be 
informed of the possible existence of contagious diseases, in 
order that the patient may be secluded from the general fam- 
ily, in some part of the main building intended for such cases, 
or in a detached building, until the true nature of the doubt- 
ful case shall be determined. A child with a contagious dis- 
ease of the skin, with whooping-cough, or some eruptive fever, 
or even with syphilis, may be the victim of exhaustion from 
heat, diarrhoea, cholera infantum, or dysentery, and may need 
the advantages of country air as much, or more, than one who 
has no such complication. 

In connection with the request of the trustees for informa- 
tion in regard to " regulations for receiving and administering 
medicines, and otherwise, to the proper object of their care," 
I propose to consider briefly the frequency and causes of sum- 
mer disease in young children in large cities. By showing 
the frequency of such diseases in large cities the wisdom of 
the charity established by Mr. Thomas Wilson will be dem- 
onstrated. By a study of the causes of this frequency, we 
shall learn much as to the proper treatment of the several 
diseases, both preventive and therapeutic, and we shall find 
that one of the most important objects for the trustees to ex- 
amine and arrange for is the character of the food to be sup- 
plied to the inmates. 

In the circular sent me by the trustees of the sanitarium is 
a table of mortality in Baltimore during the first five years of 
life in the four years 1875, 1876, 1877, and 1878. I find, 



214 SANITARY CARE AND TREATMENT OF CHILDREN. 

from this table, that 8,549 children died in the first year of 
life in these four years. Of this total, 3,930 of the deaths, or 
46 per cent, occurred during the three hot months of sum- 
mer, June, July, and August. In the second year of life 
3,563 died, of which number 1,157, or nearly 32 per cent, 
died during the three months of June, July, and August. 
Of the whole mortality under one year, therefore, nearly one 
half, and in the second year almost one third, occurred in the 
three hot months. Nothing could show more clearly the 
great danger to life in the first two years of age than these 
simple facts. 

In Philadelphia, of the total annual mortality at all ages, 
about one fourth (25.16 per cent.) occurs in the first year of 
life. Over two fifths (40.49 per cent.) of the total mortality 
occurs in the first five years of life. (Report of the Board of 
Health of the City and Port of Philadelphia, to the Mayor, 
for the Year 1874, page 134.) In the same report it is stated 
that, in the fourteen years, 1861 to 1874, of the whole num- 
ber of deaths 23.97 per cent, were in infants under one year 
of age, and 41.51 per cent, in children under five years of age. 
It is also stated, that over one third of the deaths at these 
specified ages occurred in the hot months of the year. " These 
proportions," it is added, " great as they appear, are consid- 
erably less than those in most of the large cities of the coun- 
try, and compare very favorably with statistics for the whole 
United States." 

Dr. Thomas B. Curtis, of Boston, in the article on Infant 
Mortality in Buck's Treatise on Hygiene and Public Health, 
New York, 1879, vol. ii. p. 286, says: " In the cities of 
North America, the effect of the invasion of high tempera- 
tures in each year is the same, the mortality varying, how- 
ever, in proportion to the intensity of the heat. In moder- 
ately hot summers (1867, 1871, 1873,) the mortality under 
one year in Boston is doubled or tripled during the hottest 
month, while the mortality from one to five years is increased 
by half, or at most doubled. In a very hot summer month, 
on the other hand (July, 1872), deaths under one are sud- 



SANITARY CARE AND TREATMENT OF CHILDREN. 215 

denly almost quadrupled, the deaths from one to five being 
barely doubled. Thus, we see that the distinctive influence 
of excessive heat is felt much more acutely during the first 
year of life than subsequently, while the reverse is noticeable 
with regard to the influence of winter cold, which tells se- 
verely upon children who have passed one year of age." 

One of the primary objects of the trustees of the Thomas 
Wilson Sanitarium must be, therefore, the selection of the 
site for the institution in as cool a region of country as can be 
found near Baltimore. 

Another powerful influence in determining the mortality at 
all ages, and especially in early life, is the density of the pop- 
ulation. In the Fortieth Annual Report of the Registrar 
General of England for 1877, at page 236, may be found the 
following curious and instructive statements as to the relative 
mortality according to the density of the population. The 
density is calculated upon the proximity of the population in 
yards. The proximity is given for five hundred and ninety- 
three districts of England and Wales, arranged in seven 
groups in the order of mortality. The districts of London 
are excluded. In Liverpool, the proximity being seven yards, 
the number of living out of which one will die annually is 
twenty-six, and the mean duration of life is twenty-six years. 
In Manchester, the proximity being seventeen yards, the 
number of living out of which one will die annually is thirty- 
one, and the mean duration of life twenty-nine years. At 
the other end of the scale, of three hundred and forty-five dis- 
tricts, in which the proximity is one hundred and thirty-nine 
yards, the number of living out of which one will die annually 
is fifty-three, and the mean duration of life is forty-five years. 
The smallest rate of mortality given is in fifty-three districts, 
in which, the proximity in yards being one hundred and forty- 
seven, the number of living out of which one will die annually 
is sixty, and the mean duration of life fifty-one years. 

Another cause which influences largely the mortality in 
early life is food. Children who are supplied with their nat- 
ural aliment, nursed by their own mothers, or suckled by a 



216 SANITARY CARE AND TREATMENT OF CHILDREN. 

good wet-nurse, are much less seriously influenced by the 
summer heats, and by the other unfavorable hygienic condi- 
tions of large cities, as density of population, than those who 
are deprived of this aliment. My experience in Philadelphia 
convinced me long since that hand-fed children were vastly 
more apt to die of the summer diseases than those brought 
up at the breast. In the early part of my professional life it 
was one of the traditions of the nursery that, if a child could 
but be nursed through its second summer, its chances of es- 
caping the dangers of the hot season were greatly increased, 
and women of all classes were disposed to prolong the period 
of lactation through this age ; of late years this habit or rule 
seems to be going out of fashion. Few children of the upper 
classes of society, it seems to me, are now nursed beyond the 
end of the first year. Man} 7 are weaned at the eighth and 
tenth months. 

I am of opinion that the system referred to is a wise one, 
and that it is well for women to follow it, when they can do 
so. The objection made is that it exhausts the mother. When 
this is the case, there is no alternative but to wean the child, 
since not only the mother, but the child as well, would suffer 
from such exhaustion. For a number of years past, as I 
shall state at greater length further on, I have advised nurs- 
ing women to begin to feed their children at the age of from 
three to five months, and to persevere until they are taught 
the habit. By doing this in the mode I shall recommend, the 
mother's strength is greatly husbanded, the child is brought 
gradually and with more safety to the period of weaning, and 
the flow of breast-milk is maintained to a moderate extent as 
a precious resource, should the child be attacked by any of t 
the summer diseases. 

To show the mortality of hand-fed as compared with that 
of children nursed at the breast, I will cite a statement to be 
found in Professor Kehrer's excellent lecture on the Food of 
Infants (German Clinical Lectures, Second Series, Syd. Soc. 
Ed. p. 347). Professor Kehrer quotes C. Meyer as having 
found that of 8,329 children, six months and under, who died 



SANITARY CARE AND TREATMENT OF CHILDREN 217 

in Munich from 1868 to 1870, 1,231 (that is, 14 per cent.) 
had been suckled, and 7,098 (that is, 84 per cent.) brought 
up by hand. 

It is nevertheless true that a great many children must be, 
and are, brought up on artificial food. It is important, there- 
fore, to discover, if possible, the causes of the great mortality 
in hand-fed children. The main cause is, of course, the loss 
of the natural aliment, and the impossibility thus far in the 
history of medicine of discovering any perfect substitute for it. 
The best substitute yet discovered is the milk of some one of 
the mammal class of animals. That of the ass, the goat, or 
cow is generally employed. The best is probably that of the 
ass, and it may be not difficult for the managers of the Balti- 
more Sanitarium to keep on the farm of the institution some of 
these animals to serve this purpose. But as cow's milk is the 
form of milk almost altogether employed in this country, I 
shall confine the remarks I have to make upon this subject 
to it alone. 

I shall not attempt to discuss the chemical qualities of cow's 
milk, or to trace minutely the causes of its occasional indiges- 
tibility, but shall confine myself to a consideration of facts so 
far as we know them. 

There are two points connected with the use of cow's milk 
for children which especially deserve consideration, and which 
I have learned to deem of the highest importance in practice. 
On these two points, I propose to dwell in some detail. One 
is the growing belief among practical men that the degree of 
freshness of the milk, and its preservation from all contami- 
nation with foreign matters, and specially with filth matters, 
have a great deal to do with its fitness or unfitness to serve as 
a food for the human infant. The second is the question as 
to whether it is best to use it pure for young children, or di- 
luted, and if diluted, in what proportions at different ages. 

It has long been known that cow's milk which has been 
kept too long, or which, having been preserved in unclean 
vessels, has undergone some change of a putrescent nature, is 
extremely apt to disagree with the infant and to be the cause 



218 SANITARY CARE AND TREATMENT OF CHILDREN. 

of indigestion or diarrhoea at any season, and to incite attacks 
of summer disease in hot weather. Of late years several ob- 
servers have suggested, as one chief and potential cause of 
summer disease in children fed on cow's milk, the remarkable 
tendency of this fluid to undergo, when kept for some time 
after being drawn from the cow, putrescent changes. As this 
fact, if true, must be one of great importance to the officers 
of the sanitarium, and as it is one capable in large measure of 
prevention, I need not hesitate to quote in this essay the opin- 
ions entertained upon the subject. 

Dr. Thomas B. Curtis (Buck's Hygiene and Public Health, 
vol. ii. p. 290) says : " Milk, when exposed to atmospheric 
air, is known to be excessively putrescible. So liable is it to 
become contaminated by the development of various ferments, 
that Professor Lister used it as a substitute for Pasteur's solu- 
tion in his experimental investigations into the subjects of 
fermentation and putrefaction. i Milk,' he says, ' is a pabu- 
lum for all kinds of organisms ; nearly all kinds of bacteria 
(and there are indeed very many varieties) will live in milk ; 
whereas only a small proportion of such organisms will live in 
Pasteur's solution.' Not only is milk very prone to decom- 
position, but it is exceedingly difficult to disinfect it when 
once it has begun to undergo fermentation or putrefactive 
changes, in consequence of the access of organisms." 

Dr. Curtis (loc. cit. page 291) quotes some instructive facts 
observed by Dr. Baginsky during an investigation undertaken 
to ascertain the causes of the prevalence of infantile diarrhoea 
in Berlin. He came to the conclusion that the disease was 
chiefly due to the use of improper food. " He made a series 
of comparative experiments for the purpose of ascertaining 
the degrees of putrescibility of various articles of infant food, 
comprising woman's milk, cow's milk, Swiss milk, and two 
kinds of farinaceous food. These, having been previously 
boiled, were exposed to a continuous temperature of 37° C. 
(98.6° F.)." "After twenty-eight hours' exposure to this 
temperature the woman's milk and cow's milk remained al- 
most unchanged ; but the Swiss milk, although appearing 



SAXITARY CARE AND TREATMENT OF CHILDREN. 219 

fresh, and the two farinaceous foods, exhibited bacteria in ac- 
tive motion. The woman's milk was alkaline, the cow's milk 
slightly acid, and the farinaceous foods strongly acid. After 
a further exposure of eighteen hours, the cow's milk and the 
Swiss milk were coagulated, and the farinaceous foods in a 
high state of putrefaction ; the woman's milk remaining still 
alkaline and almost unchanged. The experiments were re- 
peated many times, and always with the same results. They 
were also varied, and it was found that by careful manipula- 
tions and the use of distilled water, these changes might be 
delayed; but for all practical conclusions the first experiments 
hold good. The preeminence of woman's milk is acknowl- 
edged ; then comes cow's milk and the Swiss milk ; and only 
at a far-off distance the farinaceous foods experimented upon 
can be admitted, not as substitutes, but as merely supplement- 
ary substances, which are rendered less mischievous by the ad- 
dition of milk." 

Meissner is quoted by Dr. Curtis as asserting that cholera 
infantum never attacks children raised wholly upon breast- 
milk, and as being a determined advocate of the bacterial the- 
ory of diarrhoeal infection. " He expresses his conviction 
that the agency which, in midsummer, in densely populated 
districts occasions fatal diarrhoea does not reside in animal 
milk per se. The pernicious agent, he says, must be sought 
solely in the drawn milk resulting from the access of atmos- 
pheric air, and from the imperfect cleansing of the vessels in 
which the milk is kept and transported, and of the bottles, 
tubes, and mouth-pieces through which it is administered to 
infants." 

I will state at this point, that my own experience does not 
agree with Meissner's that nursing children never have cholera 
infantum. They certainly do have it in Philadelphia, but 
much more rarely in comparison with hand-fed children, nor 
do they have it so severely, nor in so dangerous or fatal a 
form. 

These experiments of Baginsky tend to confirm the opinion 
expressed by Mr. Simon, in 1858, to the General Board of 



220 SANITARY CARE AND TREATMENT OF CHILDREN. 

Health of London, to the effect that " diarrhoeal infection 
owes its prevalence to infection by filth" See article by Dr. 
Curtis, in Buck's Hygiene and Public Health, vol. ii. p. 290. 

These views, which seem to be consonant with both theory 
and practice, may be of great service in guiding the officers 
of the sanitarium to a more successful use of cow's milk for 
the children who are to become the inmates of the institution. 
They show how important it may be in the economy of the 
institution to have the supply of milk drawn from the cow 
twice, or even three times a day. The proper care of the 
dairy, and a rigid inspection of all the vessels, utensils, cups, 
or bottles, intended for the younger children in particular, 
whose almost sole food must be milk, becomes a matter of 
singular importance. 

It would be well, too, it seems to me, to discard, as far as 
possible, in this institution the use of sucking bottles, with 
their tubes and mouth-pieces. It is very difficult to keep 
these instruments perfectly sweet and clean, even in private 
families, where each young child has a mother or nurse, whose 
whole time and care are given for it alone. How much more 
difficult in an institution where each nurse must have the care 
of five or six or more children. 

They can, I think, be safely dispensed with at the age of 
three or four months. Prior to that time, a common four or 
six ounce bottle, with a rubber mouth-piece or nipple slipped 
over the mouth of the phial answers every necessary pur- 
pose. This simple contrivance has the inestimable advan- 
tage of being easily kept clean, or, at least, much more easily 
than any of the more elaborate apparatus. Even this mouth- 
piece will soon become foul unless kept soaking in water be- 
tween the periods of use. The bottle itself ought to be care- 
fully cleansed after being used. In my own family I always 
used for the purpose of feeding, at the ages mentioned, a small 
glass or silver cup with a handle. I advise the use, at the 
sanitarium, of glass cups or small tumblers. There is no 
other material so readily kept clean, and none which can be 
more easily inspected by the proper officer. 



SANITARY CARE AND TREATMENT OF CHILDREN. 221 

In a foot-note at page 427 of M. Parrot's work on Athrep- 
sia it is stated that in the foundling hospital of Moscow the 
children are half fed and half nursed, and that the only feed- 
ing vessels employed are made of glass, and have no nipple. 

I will mention that I have, for many years past, been in 
the habit of advising my patients to begin to feed their chil- 
dren on artificial food at the age of three or four months. I' 
did this in my own family and had no cause to regret it. I 
have followed this system for several reasons. In the first 
place, the child is taught to feed from an open vessel, instead 
of sucking from a bottle with its mouth-piece or tubes, which 
are so prone to become offensive that only the vigilant eye of 
a sensible mother or trained nurse can prevent it. The mere 
habit of taking food from a cup prepares the child to undergo 
weaning with much less trouble than when it is weaned ab- 
ruptly from the breast, and, lastly, the digestive organs be- 
come habituated by degrees to the reception and digestion of 
the new food. In advising this course I am careful to order 
only one feeding a day for the first two or three months. 
Afterwards, as the child strengthens, it is fed two or three 
times, and, in the second year, if the mother is able to nurse 
the second summer, I prescribe enough food to make it nec- 
essary for the mother to nurse only three or four times a day. 

I pass on now, under the request of the trustees for infor- 
mation as to " regulations for receiving and administering 
medically and otherwise to the proper object of their care," 
to the subject of the food to be supplied to the young chil- 
dren who are to be the inmates of the institution. There are 
few practical subjects within the domain of the medical art 
more difficult to deal with, about which more confusion and 
uncertainty prevails, than the simple one of the food for young 
children. 

My remarks will be confined almost exclusively to cow's 
milk. Should the officers of the sanitarium see fit, and find 
it possible, to have a few wet-nurses at the institution, for 
very young hand-fed infants who may arrive at the establish- 
ment dangerously ill, whether from heat, the malaria of the 



222 SANITARY CARE AND TREATMENT OF CHILDREN. 

city, or improper food, and whose lives might, perchance, be 
saved by nursing for a few days or weeks, it would be well. 
They might also, perhaps, as was suggested before, have a 
few asses on the farm attached to the sanitarium, for the rea- 
son that the milk of this animal resembles human milk more 
nearly than does that of any other animal. But cow's milk 
will undoubtedly constitute almost the sole supply of food for 
children under one year of age, the chief supply for those in 
the second year of life, and a large proportion of what will be 
required for those over the last mentioned age. 

In seeking to determine how we are to feed children who 
have been deprived of the breast, I can conceive of no method 
so likely to lead to correct results as the very simple one of 
taking nature for our guide. By ascertaining the quantity of 
milk a healthy nursing woman furnishes at different periods 
of lactation, we determine the amount of liquid food we must 
administer to the hand-fed child, always bearing in mind that 
the food we choose shall resemble the natural aliment as 
nearly as possible. By careful comparison of the proportions 
of the constituents of cow's milk with those of woman's milk, 
we are enabled to bring the former, by the addition of water, 
sugar, and sometimes of cream, to a physical constitution much 
more like the latter than it is in its natural state. At least 
this is my opinion. We have, besides the comparison of the 
physical qualities of the two kinds of milk, long experience to 
assist us in determining the relative value of cow's milk vari- 
ously prepared. 

I have found very few statements by medical writers as to 
the quantity of milk furnished by nursing women, and the 
few that I have found differ so much from each other that I 
deem them of very moderate value. In the recent very able 
work by M. Parrot, of Paris, on Athrepsia, the author quotes 
Dr. N. Guillot as assuming from his observations that a child 
two days old takes from the breast twenty-one ounces of 
milk ; one of five days, seventy-eight ounces ; and one of 
eighteen days, ninety-one ounces. These amounts are, ac- 
cording to M. Parrot, entirely too large. He quotes, with 



SANITARY CARE AND TREATMENT OF CHILDREN. 223 

strong approval, some observations made by Dr. Bouchard, at 
the Maternity Hospital at Paris. Dr. Bouchard concluded 
that a child one day old takes one ounce of milk per day ; one 
of two days five ounces ; at four days seventeen ounces ; after 
the first month, twenty ounces ; after the third month, 
twenty-three ounces ; after the fourth, twenty-seven ounces ; 
and from six to nine months, thirty ounces. M. Parrot says 
of these results of Dr. Bouchard : " I accept them entirely, 
after having determined their correctness by observations of 
my own." I may add that Guillot's results were obtained by 
weighing the child before and after the act of nursing. But 
this was done only for one nursing. He then assumed that 
the child nursed no less than twenty-five times in the twenty- 
four hours, and multiplied this number by the weight gained 
at the one nursing. Dr. Bouchard, on the contrary, weighed 
the children observed by him before and after the act of nurs- 
ing, and each time in the day that the act was performed. 
He found the average number of nursings in one day to be 
from eight to ten. 

My own observations amount to only three in number, but 
the mode of determination of the amount of milk yielded in 
each case was so necessarily exact, that I have entire faith in 
their accuracy so far as they go. The milk was drawn from 
the breasts by a breast-pump in each case, and then accurately 
measured. 

The first observation was made some thirty years since. A 
healthy woman, whose mother was a monthly nurse, was con- 
fined of a still-born child. The flow of milk was kept up by 
means of a young puppy. At the end of six weeks, she ob- 
tained a place as wet-nurse, and the day before she went to 
her place, I had all the milk her breasts furnished for twenty- 
four hours, drawn by a good breast-pump. It measured ex- 
actly a quart. I measured it myself. Is it not reasonable to 
suppose that, had the breast-glands been stimulated in this 
woman in the natural method, to wit, by the maternal in- 
stinct and by the suction of a healthy child, the amount would 
have been larger — say three pints. Since that period, I have 



224 SANITARY CARE AND TREATMENT OF CHILDREN. 

had two admirable opportunities for determining exactly the 
amount of milk supplied by a healthy woman. In one case, 
a child four months old, suddenly, owing to a long illness from 
a chronic suppuration, weaned itself from its mother. It was 
fed for a time on cow's milk, with Mellin's food, but becom- 
ing very ill, I sent for a wet-nurse. The child could not be 
induced to take the breast, and the milk was therefore drawn 
by a breast-pump, and fed to the child from an ordinary 
nursing-bottle. The wet-nurse's child was at this time two 
months old. At first only small quantities, one and two 
ounces, were retained ; but after several days the child took 
daily of this milk as much as 36 ounces. Besides this quan- 
tity, which was drawn regularly by the breast-pump, the nurse 
suckled her own child in part. Assuming that she gave her 
own child a pint, we find that the amount supplied by her 
was fully three pints, or 48 ounces daily. 

In the second case, a child born of a very healthy young 
woman was unable to nurse because of a congenital defect of 
the mouth. The milk was drawn by a breast-pump, and ad- 
ministered from a sucking-bottle. When the child was five 
and six weeks old, it was taking 18 and 23 ounces per day. 
But, at the same time, the quantity drawn each day from the 
breasts, accurately measured, was 39-f, 41, 33|, 39, 39i, 39J, 
31J, 41|-, 44i, 35, 40, and 39£ ounces. The largest amount 
any one day, in this case, was therefore 44J, and the smallest 
31| ounces. Is it not probable that, had the breasts been stim- 
ulated in the natural way in this woman, the quantity would 
have been greater rather than less ? 

The difference in the estimates given by M. Parrot and 
myself are certainly curious. He supposes that a child re- 
ceives from its mother in the second month, 20 ounces of 
milk per day ; after the third month, 23 ounces ; and from 
the sixth to the ninth month, 30 ounces. My observations 
show that one woman supplied at the end of the sixth week 
32 ounces; another, in the second month, 36 measured ounces 
drawn from the breast, and some given to her own child by 
nursing ; the whole amounting probably to 48 ounces ; and 



SANITARY CARE AND TREATMENT OF CHILDREN 225 

a third who gave in the fifth and sixth week of lactation, 
from 31^ to 44J ounces each day. 

I feel so sure of the correctness of these observations that I 
shall take them as the guide for determining the amount of 
liquid food that children in good health ought to take at the 
ages mentioned. 

I proceed next to set down in detail what I conceive to be 
the best method of feeding children deprived of the breast. 
I shall, with a special view to the needs of the Baltimore 
Sanitarium, refer first to the diet for healthy children and 
those convalescent from disease, and second, to that which 
may be proper for those who arrive at the institution suffer- 
ing from indigestions, diarrhoeas, cholera infantum, dysen- 
tery, and general debility, induced by the summer heat of the 
city. 

In a large institution, such as the sanitarium is probably 
destined to be, the more simply the food can be prepared, the 
better for all concerned. I advise therefore that, as a general 
rule, the milk should be used diluted with simple water in the 
proper proportions. Milk containing fifteen per cent, of cream 
is the kind I prefer, when it can be had ; but as eight and 
ten per cent, of cream are considered a fair average, I assume 
in the rules I mention that the cream is ten per cent. 

If the child be young, one to three months old or younger, 
I advise the addition at first, until the degree of digestive 
force of the particular child may have been determined by ob- 
servation, of two parts of w r ater. To each pint of this mixture 
should be added half an ounce of sugar of milk, or half the 
quantity (two drachms) of cane sugar. After it has been as- 
certained that food of this strength is well borne, the patient 
may be put upon the proportion generally to be employed at 
the age of the child, whatever that may be. 

From birth to the end of the first month, and often in the 
second month, the proportion of two parts water to one of milk 
is the one I deem the safest and best. In the second month, 
and up to five or six months, the proportion ought to be half 
and half in healthy children. After this period it may be 

15 



226 SANITARY CARE AND TREATMENT OF CHILDREN. 

made two parts milk and one water until the end of the first 
year. 

In children in the second year of life the milk may often 
be given pure, though even at this age I have met with many 
cases in which the permanent addition of a fourth or a third 
of water renders the food more digestible, and productive of 
better results. So long as the child thrives well on diluted 
milk, there can be no valid objection, especially during the 
hot season, to a continuance of its use. It is certainly true 
that nature does not increase materially the richness of the 
breast-milk in the second year of nursing. 

The exact quantity of food required by different children 
varies according to their constitutional peculiarities. The 
proper amount in each instance can be determined only by 
the careful observation of an intelligent and experienced phy- 
sician or nurse. Still, there ought to be, and there must be, 
some general standard for the guidance of the officers of the 
sanitarium, and especially for the nurses on whom will de- 
volve the task of supplying to the various patients what they 
may need. 

I have already stated, as the result of my own observations, 
that nature supplies to the child, in the second month, as much 
as a quart per day, and in the third and fourth months three 
pints. These amounts accord closely with the quantities of 
diluted cow's milk that healthy children of good appetite and 
digestion generally take at those ages. I believe that the 
amount is not much increased between the sixth month and 
the end of the first year. Some large and healthy children 
are very hearty feeders. Some few such take as much as 
two quarts after the eighth or ninth month. 

I do not venture to lay down these standards as invariably 
right, but I do venture to say that when a child of three or 
four months old is taking only a pint of food a day, it is tak- 
ing quite . too little, and it is proper and necessary for those 
having it in charge to use every cautious endeavor to increase 
the sum. 

It is important, also, to establish some general rules as to 



SANITARY CARE AND TREATMENT OF CHILDREN. 227 

the number of feedings per day. In very early life, the first 
and second months, food should be given every two hours, so 
much at each feeding as to make the pint, pint and a half, or 
quart per daj 7 required at the different ages. From the third 
to the sixth month, the feedings may be repeated every three 
hours. If this be done from six or seven A. M. to eight or nine 
P. M. there would be six in the day. From six to eight ounces 
should be given at a time, according to the vigor and natural 
appetite of the subject, making in all from thirty-six to fort}^- 
eight ounces, or from a little over a quart to three pints. 
After eight months most hearty children will take the eight 
ounces and some even more, or they may require now and 
then a extra meal, making up the total to nearly two quarts. 

I believe it is unnecessary, as a rule, to feed children in 
good health in the night after the age of eight months. If 
the last meal be given at nine or ten P. M., the child may usu- 
ally go to six A. M. of the following day. Should it be uneasy 
in the night, a drink of plain or sweetened water ought to 
suffice. 

If the child does not thrive well on simple milk and water, 
it will be proper to add some farinaceous substance to the 
diet, and to give once or twice a day beef or chicken tea. 
The best farinaceous materials are barley, oatmeal, or arrow- 
root, the choice in each case being determined by the taste or 
fancy of the child, and by its tendency towards constipation 
or diarrhoea. In the former case oatmeal, in the latter barley 
or arrowroot, are the best. When barley or oatmeal is used, 
two teaspoonfuls of either substance should be boiled for fif- 
teen minutes in a pint of water, and the fluid strained and 
added to the milk in place of simple water. Of arrowroot 
a teaspoonful and a half to the pint of water is sufficient. 
When the barley is used, it is best to procure whole barley, 
grind it in a spice-mill, and employ the ground substance. 

When beef-tea is to be used, I think the best mode of pre- 
paring it is that recommended by Dr. Letheby of London. 
Equal weights of lean beef and cold water (a pound to the 
pint) are to be infused together for an hour. The beef and 



228 SANITARY CARE AND TREATMENT OF CHILDREN. 

water are then put into a pipkin, placed near the fire, and 
allowed to beat gradually, so that they shall reach the boiling 
point in fifteen minutes. They are allowed to boil only a few 
minutes ; I direct two minutes, in order to avoid a hard and 
tough coagulation of the albuminoid juices by more prolonged 
boiling. The water is decanted off the meat, the beef squeezed 
to obtain all the fluid, and the tea used w T ith the small and 
soft sediment which it contains. Salt, of course, is to be 
added. 

To make chicken tea for young children, I direct the half 
of a small chicken, or the leg and thigh of a large one, to be 
deprived of the skin, the bones to be broken, and the chicken 
put into a quart of w 7 ater, which is to be simmered down to a 
pint. To this sufficient salt is added. Children often take 
this thin tea with great avidity. 

I pass on, now, to the second portion of this subject, — the 
kind of food to be employed for children who arrive at the 
sanitarium suffering under the forms of disease induced by 
the heat of the city. 

In acute cholera infantum, one of the dangerous and dis- 
tressing features of the disease is the vomiting which often 
attends it. I have often seen children with this disease go to 
the breast, nurse eagerly, and vomit as though under the in- 
fluence of a powerful emetic. If this happen several times, 
the child ought to be allowed to nurse for one or two minutes 
only, when it should be removed from the breast. If this 
plan succeed, the nursing may be repeated every hour or two, 
and cool water, with half a teaspoonful of brandy to the half- 
pint, in the quantity of one or two tablespoonfuls at first, 
ought to be offered the child between the acts of nursing. 
Should even these small quantities of milk be rejected, the child 
must be withdrawn from the breast for twenty-four hours, 
and the brandy and water given frequently, in such amounts 
as the child can retain. Small doses, one or two tablespoon- 
fuls, or even teaspoonfuls, of beef tea, and especially of the 
chicken tea, may be tried every two hours, and they will often 
be retained. At the end of twenty-four hours, if the vomit- 



SANITARY CARE AND TREATMENT OF CHILDREN. 229 

ing have ceased, the child may again go to the breast, being 
allowed to nurse at first for only one or two minutes at a 
time. 

As to the amount of water to be used on these occasions, 
my own practice is to give one or two tablespoonfuls every ten 
or fifteen minutes, until I find that it is well borne. When 
this proves to be the case, I give all the child will take of 
with pleasure and avidity. 

When the patient with cholera infantum is weaned, and on 
artificial food, it is necessary to dilute the milk largely (half 
or even three fourths) for a day or two, and give only two or 
three. tablespoonfuls every two hours, and to allow cold water, 
or brandy and water between, as directed above. In obstinate 
vomiting, the milk ought to be withheld entirely for twenty- 
four or forty-eight hours, and the small doses, two to four 
tablespoonfuls, of beef or chicken tea given instead, once in 
two or three hours. If this quantity is not retained, a single 
tablespoonful may be given every hour, or teaspoonfuls may 
be tried every fifteen minutes. 

It is a curious fact that a young child, one of three or four 
months to one and two years old, will often take eagerly 
brandy and water, and retain it, when all food, so-called, is 
rejected. I saw a child this past winter, four months oldi 
reject, by vomiting, breast-milk drawn from the breast by a 
pump, when more than two and three tablespoonfuls were 
given at a time, who could and did take with great avidity, 
and retain, considerable draughts of cold water containing a 
teaspoonful of brandy in each half-pint. This patient drank 
in this way two and three half-pints of water in the twenty- 
four hours. After three days the appetite for the brandy and 
water passed away, and the child turned from it with loath- 
ing. Some days later the desire returned, and the fluid was 
again taken for some time, with the same eager appetite. 
The patient recovered completely in a month, and was able 
to return to the diet of cow's milk and water. A month after 
this, again, the child was taking each day two quarts of the 
gelatine, milk, and cream food, to be referred to presently. 



230 SANITARY CARE AND TREATMENT OF CHILDREN. 

When the vomiting has ceased and diarrhoea alone remains, 
and when the disease has been simply diarrhoeal from the 
first, the regulation of the food is the most essential part 
of the treatment. If the ordinary simple milk and water is 
not well borne, and if the stools contain masses of undigested 
casein, the food recommended in the work on Diseases of 
Children by Meigs and Pepper, consisting of milk and thin 
arrowroot water, with the addition of a little gelatine and 
cream, often succeeds extremely well, particularly in very 
young children. 

There is another preparation I have used in teething chil- 
dren, with severe summer diarrhoea and occasional vomiting, 
with excellent results. It consists of equal parts of thin ar- 
rowroot water, lime-water, cream, and ordinary milk. The 
arrowroot water is made of a small teaspoonful of that sub- 
stance to the half-pint of water. One tablespoonf ul of each of 
the ingredients, making two ounces, is given every two hours 
at first. In a day or two, three ounces, and afterwards four 
ounces, are allowed every two hours. If the diarrhoea im- 
prove, and the appetite increase, the proportions of the ingre- 
dients may be changed. The milk may be increased and the 
cream diminished, and the patient restored gradually to its or- 
dinary food. 

I am well aware of the fact that some writers of authority 
oppose the addition of cream to ordinary cow's milk, on the 
ground that any excess of cream is injurious rather than bene- 
ficial. The objection, however, seems to me to be based upon 
theoretical rather than upon practical reasons. I have employed 
the food referred to above, made of arrowroot water, gelatine, 
milk, and a small additional amount of cream, with sugar, for 
many years with much success, and I know that it has been 
used a good deal by others. Moreover, the second preparation 
mentioned above, consisting of milk, cream, lime-water, and 
arrowroot water, in equal proportions, in cases of acute sum- 
mer diarrhoea, has answered admirably well in my hands in 
a good many cases. It is twenty-three years since, in a case 
of severe typhoid fever in a boy ten months of age, who had 



SANITARY CARE AND TREATMENT OF CHILDREN. 231 

been recently weaned, and whose digestive powers were at a 
very low ebb, I asked my father, Prof. Charles D. Meigs, 
what diet I should give the child. He advised me to have a 
thin arrowroot water made, and to add two tablespoonfuls 
of pure cream to six ounces of water, with a little sugar. The 
child took this food freely, lived on it for a number of days, 
recovered, and is now a vigorous and healthy man. In an- 
other boy, in the second year of life, I found it impossible 
for him to digest ordinary cow's milk, either pure or diluted. 
It invariably brought on diarrhoea, and I was compelled, after 
a number of trials, to use cream alone, diluted with water. 
He took a pint of the cream daily, with small quantities 
of beef or chicken tea and some bread. He was pale and 
weak-looking during all this time, but got safely through his 
dentition and is now a healthy, active boy of twelve years of 
age. 

I am acquainted with the history of a family in this city, in 
which the mother (not under my advice) has brought up 
three children, chiefly on cream. Two were fed from birth 
on it ; at first, they had a gill a day, then half a pint, and 
afterwards a pint a day. Two parts of water, and sugar, were 
added to the cream. In the second year, milk w T as added to 
the cream until a quart of each was taken daily. The last 
child, now eleven months old, a healthy-looking and well- 
grown child, is partly nursed, but takes a pint of cream mixed 
with water daily. None of those three children, the mother 
assures me, have ever had cholera infantum. I do not men- 
tion these facts as an advocate of the use of cream, saving in 
exceptional cases, but as showing how true it is that children 
have their idiosyncrasies. Children, like adults, are a law to 
themselves, and he is the successful physician who discovers 
the law of each patient, and so is enabled to carry him 
through some special crisis of his life. 

When diarrhoea in teething children -becomes chronic, in 
addition to the catarrhal state of the bowel a serious dyspeptic 
condition is set up, and the child often loses all appetite, iv L 'uses 
ordinary food, emaciates, and is in great danger of sinking 



232 SANITARY CARE AND TREATMENT OF CHILDREN. 

from a slow inanition. In this state I have known life saved 
by a resort to articles of food which would not, and ought 
not, to be thought of in ordinary cases. This form or stage 
of digestive disorder seldom occurs except in teething children. 
I have seen it at the ages usually of eight or ten months to 
the close of the second year. The child, like some dyspeptic 
adults, comes to loathe its accustomed food. Under these cir- 
cumstances, I have learned to study what Dr. Joseph Parrish 
of this city often called the language of the stomach, — to offer 
new and unusual articles of food, until I find something which 
is taken eagerly or at least willingly. Pieces of stale bread cut 
thin, and spread with a little currant-jelly, are often very ac- 
ceptable, and they very seldom disagree with the child. Slices 
of bread, lightly toasted, with beef-tea, or pure beef-juice 
squeezed from rare or raw beef with a lemon-squeezer, poured 
over them, and salted, are frequently relished. I have used 
the yelk of an egg^ hard-boiled, broken into a powder, with 
salt, or finely minced rare beef, or mutton-chop ; or, what used 
to be famous in the nursery, a bit of fried ham, of which the 
fatty portion is often sucked with great pleasure, may be tried. 
Stale and crisp sponge-cake, in the form called finger-cakes, or 
ginger-bread made light and moderately hard, and not too 
highly spiced, are useful. In one case, I saw a child take the 
roe of herring sprinkled over bread, from time to time, and 
then begin to recover appetite. Lumps of white sugar, or 
small portions of good mint-candy, may be allowed. The prep- 
aration of chocolate called Rackahout, or very thin chocolate, 
made partly of milk, is sometimes liked, when all ordinary 
food is refused. In such cases great danger arises from the 
slow inanition going on ; and if we can prolong life for a few 
days, and at the same time rouse the dead appetite, and 
stimulate the salivary and gastric glands to renewed action, 
life may be saved. If this plan be followed carefully, and the 
various articles named tried in succession, we shall often be 
able to find something that will be taken willingly. 

The trustees ask for " your suggestions in regard to the 
most practicable means of lessening the risks and dangers in_ 



SANITARY CARE AND TREATMENT OF CHILDREN. 233 

cident to children exposed to the heated and impure atmos- 
phere of a large city, during the summer months." 

These " risks and dangers " can be lessened only by the 
removal, when removable, or by the lessening, when irre- 
movable, of the causes which give rise to them. The chief 
causes of danger are heat, uncleanliness, density of population, 
and improper or unwholesome food. The heat is greater in 
the cities than in the rural districts, and it is more fatal. One 
cause of the greater heat is the diminished movement, and the 
stagnant condition of the air in the streets, and these condi- 
tions are most marked, of course, in the narrower streets, and 
especially in the blind courts and alleys, where the poor and 
unfortunate are often compelled to live. Our large cities can- 
not unbuild themselves, but they might, by municipal author- 
ity, determine that, in the future, the main streets should be 
made wide avenues, and that no streets shall be opened of less 
than a certain width, and no blind alleys nor courts whatever. 
Let each city insist on a plan, hereafter, which shall secure a 
free and unimpeded movement of the air, and she will soon 
lessen the mortality of the population, and especially of her 
young children. The refusal of permission to open any more 
streets below a certain width, or of any blind courts or alleys 
whatever, would have another most useful result. It would 
diminish the density of the population, which, as has been 
shown, is a large factor in the determination of the death-rate, 
and of the expectation of life, in the population. 

The establishment in a city of as many open squares or 
parks as possible tends to diminish heat by increasing the ven- 
tilation, and by the effect of trees and grass, and to improve 
the purity of the atmosphere. The gift of such open spaces by 
munificent citizens, their retention in the original plans of the 
town, or their purchase by the municipality, would' diminish 
the intensity of two causes which act so fatally on children, — 
heat, and density of population. 

To diminish the injurious effects of heat in summer, the 
houses ought to be built with considerable window-space. It 
might be enacted as a law that no house shall be erected in 



234 SAXITARY CARE AXD TREATMENT OF CHILDREN. 

future with less than a certain amount of window-space. Nor 
should any house be erected without windows opening on two 
sides, front and back, if possible, so as to secure a free venti- 
lation through the main body of the house. 

The windows of the upper rooms of the house, at least, 
ought to be hung with shatters of the Venetian pattern, so 
that currents of air may pass freely, while the brilliant light 
of midday may be excluded. 

The houses should be built with an open fireplace in each 
room, to promote thorough ventilation in summer. And when 
this cannot be done, and the house is warmed by a furnace 
alone, ventilating flues should be run through the walls. 

Besides heat and density of population, one of the chief 
causes of infant mortality is unwholesome food, and especially, 
as would seem from modern investigations, stale and impure 
milk. To lessen this cause, each city ought to have a legalized 
inspector of milk, who, after a certain standard quality of 
milk shall have been agreed upon, ought to make frequent in- 
spection and occasional analysis of the milk, to see that the 
provisions of the law are carried out. One part of his duty 
ought to be to see that the vessels in which the milk is carried 
to and transported about the cities are kept pure and clean. 
Any milkman whose vessels are unclean and foul ought to be 
suppressed as a public nuisance. 

Uncleanliness in the household being another cause of dis- 
ease, and one especially rife among the poor, the supply of 
water ought to be large and its cost as moderate as possible. 

In the ninth Report of the Registrar General of England, 
for 1846, it is stated, page 27, speaking of Manchester : " The 
house and the children of a laboring man can only be kept 
clean and healthy by the assiduous labor of a well-trained, 
industrious wife, as any one who has paid the least attention 
to the subject is well aware." 

Dr. Curtis 1 goes so far as to say: "It appears probable, 
then, that the poisonous miasmata, which are evolved from 
urban filth under the influence of high temperatures, do not 
1 Buck's Hygiene and Public Health, vol. ii. page 293. 



SANITARY CARE AND TREATMENT OF CHILDREN. 235 

exert their universally recognized noxious action upon the in- 
fant directly by inhalation, but indirectly through the inter- 
mediate instrumentality of putrescible articles of diet. The 
injurious agent by which this particular form of filth infection 
takes place is rotten food taken into the stomach rather than 
foul air taken into the lungs." If the city could allow one 
faucet to each house, free of cost, or at a very low rate, it 
would be a great boon to the poor. Possibly, if the poor house- 
wife could afford, like the rich, to have a faucet on each story 
of her house, instead of running to the hydrant in the yard for 
all her water, she might learn to be more liberal in its use, 
and thereby keep her house, herself, and her children cleaner 
and fresher. The husband, too, when he returns from his 
day's labor, reeking with sweat and begrimed with the dust 
of his necessary toil, might then purify himself from all these 
sources of unwholesome odors, which assist to poison the air of 
his small rooms. 

The trustees desire, moreover, " your views as to the best 
methods of extending a general knowledge of simple hygienic 
rules for the treatment of children at home among the poorer 
classes." 

I can think of but two modes in which the poorer and more 
illiterate classes of society can be taught better hygienic rules 
for the treatment of children at home. One is by gratuitous 
distribution of a proper tract or tracts on the subject, and the 
other (this would apply only to Baltimore) would be for the 
Baltimore Sanitarium to make it one of the duties of its offi- 
cers (not medical alone) to endeavor, in their intercourse 
with the poor, to teach them such simple rules as may be nec- 
essary. I suggested, in the early part of this essay, that the 
institution should have in its employment, in Baltimore, a 
few elderly, respectable women or nurses, who might, when 
the mother of an ill child is compelled to leave other children 
helpless at home, take her place in the household during her 
enforced absence. If this plan were adopted, these women, 
with a very little previous training, might do more to promote 
correct views of hygiene amongst the poor than many tracts. 



i 

236 SANITARY CARE AND TREATMENT OF CHILDREN. 

If it is determined to publish a tract on this subject, I sug- 
gest something like the following. 

SHORT HINTS TO THE POOR FOE, THE CARE OF YOUNG CHIL- 
DREN DETAINED IN LARGE CITIES DURING HOT WEATH- 
ER. 

There is no one thing so essential to the safety and health 
of a young infant as breast-milk. 

Let the mother therefore use every care to keep the supply 
of this food which nature gives her. To attain this end, the 
father of the house should be willing and anxious to toil for 
the income necessary to enable the mother to remain at home, 
taking care of the household, and nursing her child, for the 
first year or year and a half. Let her suckle her child, if 
possible, through its second summer, feeding it in part, large 
part, if she will, but keeping the flow of the milk in the 
breasts to fall back upon, should the baby be taken ill. 

The father, to enable his wife to do this, must avoid intem- 
perance. The money spent in drink by the intemperate man 
would supply food for the mother, and, when necessary, milk 
for the child. 

Let the mother see to it that the house is kept clean and 
sweet. To effect this, she must not be afraid of using water 
freely to keep the floors and culinary vessels, and, above all, 
the vessels for holding milk or broths, clean. 

Carpets, especially old ones, must be taken up, beaten, and 
hung in the open air, to rid them of the dust and filth-par- 
ticles, which will cling to them when not thus treated. An old, 
soiled carpet gives out, when kept long on the floor, a most 
foul and musty odor, w T hich is a sure sign that it needs a good 
ventilating. 

When the hot days of summer arrive, when the tempera- 
ture rises to 80° and 90 ° in the shade, let the mother beware. 
One or two such days will often double the mortality amongst 
young children. The house must be well ventilated. There 
is much more danger from a close, musty, and stagnant atmos- 
phere in the house than from any currents or draughts neces- 



SANITARY CARE AXD TREATMENT OF CHILDREN. 237 

sary to change the air constantly. Chimney-places should be 
kept permanently open. Windows must be opened, and in 
hot weather kept open day and night. If the temperature 
rise in the rooms at night (and every mother ought to have 
a thermometer and learn to read and use it) above 90°, not 
only should windows be opened but doors as well. It is im- 
possible to have too much air in the house in such weather, 
unless it is blowing a gale from a thunder-gust, and then the 
thermometer will soon fall below 90°. 

During these spells of extreme heat everything should be 
done to keep children cool. They should be bathed in water 
from which the chill has been taken, or washed in cool water 
morning and evening. All heavy clothing must be removed. 
The thinnest possible flannel or merino shirt on the body, 
with a muslin frock, are all that the child needs. He should 
sleep on a firm mattress or a paillasse, dressed in a thin 
flannel or merino undershirt, and a muslin night-dress. He 
needs no flannel petticoat, and should be covered only with a 
sheet. No blankets, and above all no old family shawls, ought 
to be wrapped about a young child on a hot night. The dan- 
ger from over-heating at such times is far greater than any 
that will arise from light covering and abundance of fresh air 
through open windows. 

Children who are hand-fed entirely, or in part, must have 
the simplest food. In the first year no other food than one 
of which milk is the base, with sometimes a little beef or 
chicken tea, ought to be allowed. The milk of the cow, goat, 
or ass may be used. In this country cow's milk is nearly al- 
ways employed. To be sure that this is fresh and pure when 
it reaches the house must be one of the mother's chief anxie- 
ties. She ought to know her milkman personally, in order to 
judge whether he be honest and painstaking or not. If she 
can discover one who brings his milk from a farm of his 
own, it is best to do so. The milk must be taken, of course, 
once a day, and in very hot weather, if a fresh supply could 
be obtained in the afternoon, it would be a great safeguard 
against illness. When the milk is taken but once a day, it 



238 SANITARY CARE AND TREATMENT OF CHILDREN. 

should be boiled directly upon being received, in hot weather. 
Boiled milk keeps sweet longer than unboiled. In very hot 
weather the addition of ten to twelve grains of carbonate or 
bicarbonate of soda to each pint of milk assists greatly in 
keeping it from becoming acid. But however good and per- 
fect the milk may be when received, it will not continue so 
long unless the mother take good care of it after it has come 
into her hands. If put into unclean or partially foul vessels, 
if set down near half-spoiled meats, or old decaying vegetables, 
or in an unclean, stinking cellar, with a filthy atmosphere 
round about it, it will soon itself become more or less putres- 
cent, and when given to a child in this state it becomes one 
of the most potent excitants of summer disease that can be 
found. 

When the child is over four or five months, let it be taught 
to drink from a small glass tumbler or china cup instead of 
from sucking-bottles. Such vessels are much more easily, and 
therefore certainly, kept clean and sweet than any sucking- 
bottle. When the child is younger than this, and when it 
must be fed from a bottle, the simpler the one used the better. 
An ordinary medicine-bottle of four, six, or eight ounces, ac- 
cording to the age of the child, with a common India-rubber 
nipple or mouthpiece, makes the best apparatus. Between 
the feedings the bottle must be carefully cleansed with boil- 
ing water, and both it and the rubber nipple kept in water. 

Give the child no anodynes, no medicines, no stimulus, un- 
less it be ill. Then send for a physician. Take care at all 
seasons, but take care especially in hot weather, to offer chil- 
dren who cannot yet indicate their wants, cool water fre- 
quently through the day. In very hot weather, a child of a 
few months old needs more water than it gets in its mother's 
milk or in cow's milk. Let it drink all the water it wants. 
It ought to want a wineglassful, or more, several times a 
day. 



CAUSES OF THE GREAT MORTALITY OF YOUNG 
CHILDREN IN CITIES DURING THE SUMMER 
SEASON, AND THE HYGIENIC MEASURES RE- 
QUIRED FOR PREVENTION. 

BY J. LEWIS SMITH, M. D., 

Of Neio York. 

PREFATORY NOTE. 

" The Thomas Wilson Sanitarium for Children of Baltimore 
City," was incorporated " for the purpose of securing a sum- 
mer retreat for sick children from the heat and unhealthful- 
ness of the city, and for such other kindred purposes as may 
be hereafter determined upon by the corporation." Mr. Wil- 
son gives the following reason for making the bequest : " I 
have observed for many years, with much concern, the great 
and alarming mortality which occurs each summer among 
young children deprived by misfortune of their parents of all 
opportunity for removal from the heated and fatal atmosphere 
of the city." In executing the trust committed to their care, 
the trustees secured a tract of land, consisting of one hundred 
and fifty acres, about six hundred feet elevation above sea- 
level, and distant from the city one half-hour by railroad. The 
information which the trustees seek from essayists may be 
presented in the following propositions embodied in their cir- 
cular of December 3, 1879 : — 

I. The best methods of extending a general knowledge of 
simple hygienic rules for the treatment of children at home 
among the poorer classes. 

II. The most practicable means of lessening the risks and 
dangers incident to children exposed to the heated and im- 
pure atmosphere of a large city during the summer months. 

III. The regulations suitable for receiving and administer- 



240 MORTALITY OF YOUNG CHILDREN IN CITIES. 

ing, medically or otherwise, to those who shall be the proper 
objects of their care, special reference being made to the char- 
acter, isolation, and grouping of the requisite buildings and 
provision for mothers or nurses accompanying their children. 

The trustees add : " In the fulfillment of their duties they 
hope," at least, " to show a model of experiment, which may 
prove of value as a contribution to the best means of lessen- 
ing the mortality and promoting the welfare of young children 
here and in other large cities." It is apparent, from these 
quotations, that while Mr. Wilson especially contemplated 
making provision for the care of sick children in a summer 
retreat during the summer months, he still empowered his 
executors to devote his bequest to " such other kindred pur- 
poses " as they might determine upon. The trustees evidently 
regard a sanitarium as the main feature of the scheme to be 
carried out, and have accordingly given due prominence to 
that part of the plan by purchasing the site and specifying 
some of the details of arrangement. They have, however, 
somewhat extended their inquiries beyond the sanitarium, and 
in general language invite the discussion of the proper care of 
sick children of the poor, as to the hygiene of their homes, 
and the prevention of sickness during the heated months, in 
the following language : " The trustees wish your suggestions 
in reference to the most practicable means of lessening the 
risks and dangers incident to children exposed to the heated 
and impure atmosphere of a large city during the siimmer 
months, also your views as to the best methods of extending a 
general knowledge of simple hygienic rules for the treatment 
of children at home among the poorer classes." It is in this 
larger sense that this paper is written. 

The following essay will consist of three parts. In the first 
we will explain in what way the summer season is so fatal to 
children ; in the second what remedies should be employed, 
and how the sanitarium should be constructed and conducted ; 
while the third part will be devoted to the consideration of 
the hygienic care of the children in the sanitarium or else- 
where. The first and third parts will furnish information 



MORTALITY OF YOUNG CHILDREN IN CITIES. 241 

upon such subjects as family visitors in Baltimore, who may 
be employed by the Association, should fully understand, and 
such information also as it would be proper to impart to poor 
families of the city, by tracts or other cheap publications. 

PART I. 



TEMPERATURE AND MORTALITY ; DISEASES. 

Baltimore city, in latitude 39° 17', has a summer tempera- 
ture which varies between 50° and 99° Fahrenheit. Its mean 
temperature in the three summer months in four consecutive 
years was as follows : In 1875, 74.6° ; in 1876, 76.6° ; in 1877, 
76°; and in 1878, 75.3°. The following thermometric statis- 
tics of these four years — those of last year I do not possess — 
correspond, as will be seen, with the statement made in the 
"Encyclopaedia Britannica " in reference to Baltimore, to 
wit : " Its mean annual temperature is 56° Fahrenheit ; the 
mean summer and winter temperatures 76° and 36° respect- 
ively." 

Temperature of Baltimore. 





Highest and Lowest. 




Mean Monthly. 




Months. 












1875 


1876 


1877 


1878 


1875 


1876 


1877 


1878 


January 


52- 1 


71-17 


54- 1 


57- 6 


30.1 


41.5 


32.1 


35.7 


February 






59- 3 


65-12 


63-18 


63-20 


29.3 


37.8 


40.5 


47.6 


March . 






63-19 


69-12 


65- 9 


72-21 


39.5 


39.8 


41.4 


49.3 


April . . 






74-23 


75-30 


80-32 


79-42 


49.4 


52.1 


53.6 


58.7 


Mav . . 






88-42 


88-34 


92-41 


85-43 


64.1 


64.2 


62.7 


63.5 


June . . 






97-54 


95-51 


95-55 


92-51 


73.7 


75.9 


73.7 


70.1 


July . . 






96-61 


99-59 


93-64 


98-65 


78.0 


80.4 


78.7 


80.8 


August . 






88-58 


90-55 


94-63 


92-59 


73.4 


75.9 


77.6 


76.0 


September 






92-43 


88-45 


88-48 


87-47 


65.9 


65.6 


67.9 


69.3 


October . 






77-34 


77-30 


80-41 


80-35 


55.5 


52.4 


59.7 


58.7 


November 






65-16 


76-25 


68-25 


61-33 


42.9 


47.1 


48.4 


47.3 


December 






67-12 


56- 1 


67-22 


61-15 


38.3 


28.7 


43.5 


35.4 



Baltimore " is pleasantly situated on slightly undulating 
ground," and is much less densely populated than many of 
the large cities of the United States. According to the cen- 
sus of 1870 there were, in the average, only twenty-seven in- 



16 



242 MORTALITY OF YOUNG CHILDREN IN CITIES. 



dividuals to each acre within the city limits. Nevertheless, 
with apparent sanitary advantages, there is a large mortality 
of the infantile population during June, July, and August, as 
will be seen by the following table : — 

Deaths of Children under Five Tears of Age. 





1875. 


18' 


6. 


1877. 


1878. 


Months. 


o 


jj 


g! 


o 


it 


o 8 






eg 





5* 


EH* 




°ti 




£ > 


O £ 


5 * 


p.- 


O £ 


C £ 


0.5 


.• 


t * 


c > 




>- V 


or -1 


oE 


u 3 


in 


o fe 


u o» 


SH 


gfe 


■- a 




SE 




-3* 

s 

p 


39 


78 


1^ 
p 




£-a 


p 




£■3 
41 


c* 
P 






January 


133 


116 


74 


35 


121 


85 


104 


58 


29 


February . 


153 


66 


70 


131 


62 


45 


122 


112 


35 


120 


44 


3^2 


March . . 


141 


54 


54 


152 


99 


45 


144 


150 


65 


151 


68 


41 


April. . . 


113 


42 


38 


101 


56 


41 


135 


109 


42 


103 


4+ 


32 


May . . . 


119 


29 


53 


105 


63 


28 


121 


88 


44 


161 


43 


38 


( June . . . 


*. ( 23S 


43 


36 


x> (549 


88 


20 


eo (382 


176 


43 


(270 


58 


37 


[July . . . 


1 <489 


66 


49 


Si J 418 


105 


20 


S } 423 


140 


34 


8 {257 


53 


34 


( August . . 


°> (259 


91 


25 


-" ( 261 


119 


31 


M ( 248 


159 


35 


l ~ (203 


65 


35 


September . 


174 


90 


28 


154 


70 


34 


167 


109 


44 


125 


67 


34 


October . . 


165 


VI 


22 


104 


49 


22 


98 


59 


57 


117 


42 


33 


November . 


101 


46 


25 


89 


45 


25 


96 


63 


35 


116 


34 


46 


December . 


133 


68 


30 


137 


95 


52 


125 


80 


43 
518 


107 


33 


53 


Total . . 


2,216 


705 


508 


2,317 


925 


398 


2,182 


1,329 


1,834 


604 


444 



The above table is instructive. It shows that the children 
in Baltimore who suffer most from the heat and insanitary 
conditions of summer are chiefly under the age of one year. 
Therefore special regard must be had for such infants in the 
measures to be employed for the purpose of reducing the mor- 
tality of children. The table shows that the average monthly 
mortality in the first year of life during the four summers was 
382.9, while that of the remaining months of the same years 
was only 12&5. In other words, the mortality of the summer 
months was nearly threefold the average mortality of the 
spring, autumn, and winter months, as regards infants under 
the age of one year. If the mortality of infants of this age 
had averaged the same during the three hot months that it 
did during the remaining nine months, there would have sur- 
vived 573 infants in 1875, 865 in 1876, 928 in 1877, and 608 
in 1878', making an annual average saving of 743 lives. 



MORTALITY OF YOUNG CHILDREN IN CITIES. 243 

IN WHAT WAY THE SUMMER SEASON IS SO FATAL TO 

CHILDREN. 

We purpose, in this part of the essay, to consider briefly 
the nature of the diseases, to which the increase of mortality 
among children, during the summer months, in Baltimore, as 
well as other large cities of the Union, is chiefly due. If we 
obtain a clear and accurate idea of these diseases we will bet- 
ter understand what measures to employ for the purpose of 
preventing them, or rendering them milder, and more tract- 
able. We hope to be able to show why the summer weather 
is so fatal to children. 

1. General Depressing Effect of the Summer Weather. 

It is the common belief among people, derived from expe- 
rience and observation, that the prolonged elevation of temper- 
ature of the summer months impairs the appetite and diges- 
tion, produces languor, and diminishes the vitality and recuper- 
ative powers, so that one under its influence is less able to 
endure disease of whatever kind than in cool and bracing 
weather. There is, no doubt, truth in this, especially as re- 
gards infants, for they badly tolerate a high elevation of at- 
mospheric heat. Perspiring less than adults, they suffer more 
from the heat. It has not been unusual in my practice to see 
infants, after a very hot day, thirsty and fretful, sleeping little, 
with a temperature, one, two, or three degrees above the nor- 
mal, which state I could attribute to nothing except the hot 
weather. It is not unusual also that infants remaining in the 
city gain nothing in weight and strength, or lose in both dur- 
ing the three summer months. Now exhaustion is the imme- 
diate cause of a large majority of the deaths in infancy and 
childhood, and anything therefore which lowers the tone of the 
system, increases just in that proportion the gravity and danger 
of most diseases. The injurious effects of the summer season 
upon the system are only partially due to the heat, as we shall 
see hereafter, but are largely attributable to the noxious gases 
which are engendered by the heat where there is a large popu- 



244 MORTALITY OF YOUNG CHILDREN IN CITIES. 

lation, and therefore children of the city suffer more than those 
in the country from this cause. 

It is known to physicians that many constitutional and local 
maladies to which children in the summer season are liable, 
are more apt to occur when the tone of the system is lowered 
than in the state of robust health, for one who is vigorous, 
with full and active circulation, more quickly and completely 
reacts under noxious agencies, and so to speak throws off 
the disease. This is notably true of the inflammations, and 
the numerous forms of scrofulous ailments, which are so com- 
mon in the families of the poor, and which are apt to end in 
tuberculosis. Therefore the condition of the general health 
which hot weather is apt to produce in young children of the 
city may properly be regarded as a predisposing cause of the 
sickness and mortality of the summer. 

It is customary with nosologists to classify diseases in two 
divisions, the constitutional, and local; and to group the local, 
according to the part or system which they affect, namely, into 
diseases of the cutaneous, nervous, respiratory, digestive sys- 
tems, etc. There are no serious diseases of the cutaneous and 
respiratory systems, which are due to the summer weather. 
The nervous system is more frequently involved, but the most 
frequent and fatal of the summer diseases, and therefore the 
one which demands most attention, pertains primarily and 
chiefly to the digestive system. 

2. Nervous System. 

We shall see hereafter that the brain occasionally becomes 
seriously involved in the course of the diarrhceal maladies of 
young children, and that this complication is common during 
the hot months. This constitutes, indeed, one of the chief 
dangers of the summer diarrhoeas in infancy, and will be fully 
described in the appropriate place. Children as well as adults 
are occasionally overcome by heat, having a genuine coup de 
soleil. It is attended by great heat of head, drowsiness, jacti- 
tation, and perhaps convulsions. The ordinary form of con- 
vulsions in children, occurring suddenly in a very hot day, has 



MORTALITY OF YOUNG CHILDREN IN CITIES. 245 

so many causes, that it is often assigned to something else 
than the heat ; but although there may be other causes, the 
high atmospheric temperature must, in my opinion, be re- 
garded as a cooperating cause in not a few cases, and some- 
times as the chief cause. Young and nervous or susceptible 
children, who have been taken out in the sun, or have exer- 
cised or been excited in a hot room, are especially liable to 
these convulsive seizures. 

I have sometimes attributed, I think correctly, that very 
formidable disease meningitis, or inflammation of the mem- 
branes which cover the brain, to either direct exposure to the 
sun's rays, or to excessive and protracted atmospheric heat. 
Infants, whose heads are scantily covered with hair, and in 
consequence cooler, and are ordinarily in the shade, seem to 
me less frequently affected in this way than children of two 
to three years and older, whose heads are more covered, and 
who, beginning to go about, are more apt to be exposed to the 
sun, or to suffer from the heat. I may cite the following cases, 
which I have published elsewhere, as an example : July, 
1876, in New York city, was characterized by excessive and 
long-continued atmospheric heat, the temperature in the Cen- 
tral Park Observatory, in the shade, never falling below 61°, 
though never above 98°, and having a mean of 82.9°. There 
was also unusual dryness of the atmosphere, since during the 
entire month prior to July 30 there were only fourteen hours 
of rain, with a rain fall of .77 of an inch, and the average at- 
mospheric humidity was represented by 65, saturation being 
denoted by 100. During this month I treated in private 
practice four fatal cases, all between the ages of two and 
seven years, which I diagnosticated meningitis, none of them 
presenting any symptoms of otitis or tuberculosis. It would 
seem that the atmospheric heat had much to do with the de- 
velopment of the disease in these cases. One died in two 
days, but in the others there was the usual duration. Men- 
ingitis, however, occurring independently of inflammation of 
the ear or of tubercles at the base of the brain, is not common, 
and it cannot be said to increase materially the death-rate of 
the summer season. 



246 MORTALITY OF YOUNG CHILDREN IN CITIES. 

3. Digestive System. 

The Summer Diahrhcea (the summer complaint). It is 
to this disease that the increased mortality of the summer 
months is chiefly due. It is the most common and fatal of the 
summer maladies in all our large cities. The first cases begin 
to occur as the weather becomes warm in the middle of May, 
and new cases constantly occur, until the weather becomes 
cooler in October or November. Its maximum prevalence is 
in midsummer. 

The history of this disease is in the majority of instances 
as follows : The infant is observed to droop, and be less cheer- 
ful, and its alvine discharges are more frequent, and of less 
consistence than formerly. At first little attention is given 
to this change in the health by parents or nurse, who often at- 
tribute it to teething, and consider the diarrhoea a relief to 
this physiological process, so that in many instances medical 
advice is not sought till several days or weeks have passed, 
and what might in the beginning have been readily checked 
by hygienic or medicinal treatment becomes by slow increase 
a formidable malady. 

Occasionally the commencement is more abrupt. In conse- 
quence of some indigestible food, as unripe vegetables or fruits, 
pasti*}', etc., vomiting and purging are excited, which con- 
tinue till the offending substance is removed. The gastro- 
intestinal surface is irritated, and under the deleterious in- 
fluence of the hot weather the diarrhoea which has been 
established continues, having the same symptoms and ana- 
tomical characters as when it begins in the ordinary way. 

Cholera Infantum. Now and then the initial symptoms 
are very severe, indicating a form of diarrhoea which is ex- 
tremely dangerous unless speedily checked or modified. The 
infant may have endured the hot weather with little impair- 
ment of its general health or the digestive function, when 
suddenly, from the effects of a very warm day or of some 
error in the feeding, symptoms occur which resemble closely 
those of Asiatic cholera. Frequent vomiting and the purging 



MORTALITY OF YOUNG CHILDREN IN CITIES. 247 

of thin watery stools, which contain little or no solid matter 
and wet the diaper like urine, produce such rapid prostration, 
and such pinched and shrunken features, in the course of a 
single day or night, that the friends do not require to be told 
of the danger, for they perceive it in the changed physiog- 
nomy, and summon the physician early. This form of the 
disease has been long known by the name cholera infantum, 
or choleriform diarrhoea. Resembling in its symptoms Asiatic 
cholera, except that it is unattended by cramps, it neverthe- 
less has no kinship with that disease, for it occurs every sum- 
mer, quite independently of choleraic epidemics. It does not 
always occur in those whose previous health has been good, 
but it occasionally supervenes on a milder type of diarrhoea. 
However commencing, it does not continue long without 
abatement in its intensity or a fatal ending. 

Whether the summer diarrhoea begins mildly or with chol- 
eriform symptoms, whether its course be uniform, or now and 
then exacerbations occur, it causes progressive weakness, and 
emaciation as long as it lasts. In a large majority of cases, 
even when not treated, or improperly treated, it is not speed- 
ily fatal. If not controlled by remedies or a favorable turn of 
circumstances it continues for weeks. Therefore towards the 
close of warm weather, in addition to the new cases that may 
arise, there are many protracted cases that had an earlier be- 
ginning, presenting an appearance from wasting and weakness 
like that in advanced consumption. As death may occur with- 
in a few days or not till after many weeks, according to the 
severity of the attack and the strength and endurance of the 
patient, so the summer diarrhoea may be arrested within a few 
hours from its commencement, or not till after several weeks. 
But if it have continued several weeks with the usual emacia- 
tion and weakness, convalescence is necessarily very gradual. 
In no other disease in which, recovery may occur do we ob- 
serve so great loss of flesh and strength as in protracted cases 
of this malady, and in no fatal disease is it excelled, unless in 
tuberculosis. The bones become prominent, the cheeks hol- 
low and thin, the eyes sunken, with eyelids open during sleep, 



248 MORTALITY OF YOUNG CHILDREN IN CITIES. 

the walls of the chest showing deep grooves between the ribs, 
the abdomen hollow, the limbs shrunken, and the skin cover- 
ing them lying in wrinkles ; and yet many of these cases have 
received the best nursing and all the attention which the de- 
votion of a mother is able to supply. 

Although this disease affects primarily and chiefly the di- 
gestive apparatus, other organs, as might be expected when the 
general nutrition is so much impaired, suffer also. The brain 
wastes from lack of nourishment, so that the anterior fonta- 
nelle, or open space on the top of the head, is depressed, and 
the cranial bones, if not firmly united, begin to sink and over- 
ride each other. In a certain proportion of cases, in conse- 
quence of this waste of cerebral substance, and the feeble ac- 
tion of the heart, which propels the blood, passive congestion 
occurs in the veins and capillaries in depending portions of 
the brain, and in the cranial sinuses, which contain venous 
blood, and as a result some of the serum, or watery part of' 
the blood, escapes from the vessels (hydrocephalus ex vacuo) 
into the cranial cavity. When these changes occur in and 
upon the brain, cerebral symptoms appear, as drowsiness, roll- 
ing the head, apathy, tardy action of the pupils, and some- 
times irregular respiration, and diminished amount and fre- 
quency of the alvine and urinary evacuations, the result of 
impaired innervation. The London physicians of the first 
half of the present century particularly called attention to 
this state of the brain, which they designated spurious hy- 
drocephalus, or hydrocephaloid disease. 

The lungs also are not infrequently involved in protracted 
and feeble cases. A cough occurs, painless, not frequent, and 
perhaps overlooked in the presence of graver symptoms. 
This is due to a state of the pulmonary circulation, similar to 
that within the cranium, namely, a retarded flow and conse- 
quent congestion in depending portions of the lungs, due to 
the feeble propelling power of the heart, and partly, perhaps, 
to the altered state of the blood and the blood vessels. The 
pulmonary congestion thus arising (hypostasis) involves only 
a small portion of the lungs. It does not produce pain, or 



MORTALITY OF YOUNG CHILDREN IN CITIES. 249 

accelerate the respiration. It continues till a more vigorous 
state of the system, and a stronger and more active flow of 
blood are restored. This retarded encephalic and pulmonary 
circulation, and the anatomical changes to which they give 
rise, are therefore to be regarded as complications, and not es- 
sential elements. They increase the gravity of the primary 
malady, and that involving the brain is not infrequently the 
immediate cause of death. 

Obviously, in order to understand the nature of this sum- 
mer diarrhoea, and the structural and functional changes to 
which it gives rise, the pathologist must examine carefully 
and fully the state of the digestive apparatus, since in it, as 
stated above, the primary and essential lesions occur, and as 
the prominent symptoms are vomiting and diarrhoea it is evi- 
dent that the stomach and intestines are chiefly in fault. 

This malady is anatomically a catarrh or inflammation of 
the gastro-intestinal surface. The intestine consists of two 
portions, namely, an upper or small portion, which extends 
from the stomach downward, and a lower or large portion 
which, continuous with the small intestine above, extends to 
the end of the digestive canal. The designation " small " and 
" large " refers to the relative diameters of these two divisions 
of the intestinal tract. 

Although there have been frequent vomiting, we usually 
find at post-mortem examinations nearly the normal color 
and appearance of the gastric mucous membrane. It may 
be softer and more easily detached than in those who have 
died of diseases not implicating the digestive tract, but com- 
monly the redness due to increased vascularity, ordinarily 
present when a mucous surface is inflamed, is lacking, or it is 
much less marked in the stomach than in the lower portion 
of the intestinal tract. The same is true of the upper part 
of the small intestine, known as the duodenum and jejunum, 
the surface of which either has the normal color or presents 
vascular streaks, and arborizations. It is only in exceptional 
instances, according to my observations, that the stomach and 
upper part of the small intestines present decided inflam- 



250 MORTALITY OF YOUNG CHILDREN IN CITIES. 

matory lesions. Cases of this sort, which I recall to mind, 
have been chiefly young infants. But when in tracing down- 
ward the intestinal tube, we reach the middle portion of the 
small intestine, more marked evidences of inflammation ap- 
pear : the redness and thickening are more decided, and in- 
flammatory lesions occur from this point onward, with per- 
haps occasional interruptions, to near the end of the intestinal 
tube. From the lesions which it produces, namely, the red- 
ness or vascularity and thickening of the mucous membrane, 
and the occasional small, circular ulcers, like canker sores in 
the mouth, which are in many cases present in the large in- 
testine, it appears that the inflammation increases from its 
point of commencement above to its termination below. Pro- 
jecting from the inflamed surface here and there are little 
bead-like prominences, which are swollen solitary glands, and 
the destruction of which has probably caused the ulcers al- 
luded to. 

In exceptional instances, I have made post-mortem ex- 
aminations in protracted cases, as well as in those of short 
duration, without finding those marked inflammatory lesions 
which are commonly present, and which I had expected to 
observe, and it is now admitted by pathologists that a deep 
injection or vascularity may be present during life and disap- 
pear in the cadaver. In some rapidly fatal cases of cholera 
infantum the redness does not appear, or is less pronounced, 
on account of the quick extinction of life, when there is reason 
to think that if life had been prolonged for a few days there 
would have been marked inflammatory appearances. 

Such are the nature and anatomical characters of the malady, 
which causes so much sickness and mortality among the in- 
fants of our cities from May to November. Its ill effects are 
sometimes far-reaching in those who recover. So great im- 
pairment of the nutritive process for three or four months, at 
a very important time in the development, does not infre- 
quently produce diathetic diseases, as rachitis and scrofula. 

In looking for the causes of this disease, we must evidently 
consider those conditions which are peculiar to the summer, or 



MORTALITY OF YOUNG CHILDREN IN CITIES. 251 

are more operative in it than in other seasons. The condi- 
tion peculiar to the summer which is most apparent is the in- 
crease of atmospheric heat, but that this in itself does not 
cause the summer complaint is evident from the fact that in 
sparsely settled country towns there is often equal elevation 
of temperature, for many weeks, but with continued health- 
iness. The atmospheric conditions which render the summer 
months so detrimental to young children in the cities must 
be the noxious products which the heat generates, and which, 
diffused through the air, contaminate it. In the poor quarters 
of the cities, more than anywhere else, those conditions occur 
which render the atmosphere impure and unsuitable for res- 
piration. Hence those diseases which foul air produces occur 
most and present their severest type in those quarters of the 
city where the destitute, ignorant, and degraded congregate. 
One accustomed to the pure air of the country would hardly 
believe how stifling and poisonous it becomes during the hot 
summer days and close summer nights, in and around the 
apartments of the city poor. Among the causes of this foul- 
ness of the air, and the consequent sickness which it entails, 
may be mentioned too dense a population and the occupancy 
of small rooms by large families, rigid economy, and ceaseless 
endeavor to make ends meet, so that in the absorbing interest 
sanitary requirements are sadly neglected. Adults of such 
families, and children of both sexes, as soon as they are old 
enough, engage in laborious, and often dirty occupations. 
They seldom bathe, and often wear for days the same un- 
der-garments, foul with perspiration and dirt. The intemper- 
ate, vicious, and indolent, who always abound in the quarters 
of the city poor, are notoriously filthy in their habits. Chil- 
dren old enough to be in the streets, and adults away at their 
occupations, escape to a great extent the evil effects of impure 
air produced by such mode of life, but the infantile popula- 
tion a ways suffer severely. 

Families thus living, being habituated to foul air and odors, 
often do not appear to notice them, and neglect to obtain a 
purer air by open windows and doors. To add to the insalu- 



252 MORTALITY OF YOUNG CHILDREN IN CITIES. 

brity, dirty and worn-out garments, and utensils of various 
sorts, collect under their beds and in their closets. Waste 
products of the table and excrementitious substances are al- 
lowed to stand for hours in the room occupied by the family, 
or in the attached bed-room, undergoing fermentative changes* 

With such disregard of sanitary requirements in the apart- 
ments, as might be expected, the halls, stairways, areas and 
alleys, within and around the domicils, ordinarily show a simi- 
lar culpable neglect. They are seldom kept clean, when 
families in their rooms are so slovenly and dirty, being the 
receptacle to a greater or less extent of rejected and waste 
animal and vegetable matter. The fate of the infant com- 
pelled to breathe day after day an atmosphere which such 
uncleanliness produces is evident. It pines away, becomes 
pallid, perhaps exhibits strumous ailments, and in the hot 
weather is apt to have diarrhoea. At least, this is a very 
common result. If it do not suffer in the way mentioned, it 
is because there are countervailing circumstances, as an unusu- 
ally robust constitution, or it is kept much of the time in the 
open air. It is true that in our large cities, Health Boards 
have done much to mitigate the evil alluded to, producing in 
families more regard for cleanliness. Still even with vigilant 
health and police boards, it is impossible to obtain sufficient 
purity of air so essential to infantile health, when families are 
totally indifferent to hygienic requirements through ignorance, 
vice, intemperance, or poverty. No city in the United States 
has probably experienced so great sacrifice of infantile life in 
times gone by, from personal and domiciliary uncleanliness, as 
New York, of which I have been an eye-witness, but the evil 
which we have experienced in this city, in an aggravated form, 
exists in all our large cities. 

The exact changes which the atmosphere undergoes and 
the noxious principles diffused in it, which render it unwhole- 
some to man, have been only partially ascertained. We 
know that the air is the medium of communication of most 
of the infectious maladies, though the agents by which these 
maladies are propagated are so subtle that they have for the 



MORTALITY OF YOUNG CHILDREN IN CITIES. 253 

most part escaped detection. We know that when our senses 
can detect nothing wrong, the air frequently contains princi- 
ples which produce the most violent and fatal diseases ; and 
that impurities in the air arising from animal exhalations and 
excretions, and from decaying organic matter, are a common 
and potent cause of diarrhceal maladies is well established. 
The most violent and fatal disease to which the human race 
in modern times is liable, namely, Asiatic cholera, belongs to 
the class of diarrhoeas, and it always assumes its worst form 
and numbers its chief victims where the air is most tainted 
by effluvia from filthy streets and domiciles. The ravages of 
this disease chiefly occur where population is most dense and 
measures to insure personal and domiciliary cleanliness and 
purity of air are neglected. I might mention striking and 
pertinent examples which I witnessed in New York during 
the cholera of 1854, which ravaged chiefly the families living 
along the dirty streets and in tenement houses, and those 
whose occupations necessitated the respiration of a foul at- 
mosphere. Moreover, an interesting fact often observed in 
the dirty sections of the city, and in the crowded tenements 
where the air was sensibly impure, during the epidemic of that 
year, and in similar epidemics of cholera, deserves mention, 
namely, that persons exposed to the anti-hygienic conditions 
which predispose to cholera were apt to have diarrhoea very 
similar to the ordinary infantile summer complaint, whether 
or not they afterwards had a true choleraic attack. 

But each summer furnishes abundant direct observations, 
showing that foul air sustains a causative relation to infantile 
diarrhoea. Several years ago, while serving as sanitary in- 
spector for the Citizen's Association, my attention was par- 
ticularly arrested by the state of one of the streets which was 
not sewered, though supplied by Croton water, and was 
densely populated on either side by families mainly of foreign 
birth. The ashes and garbage were placed in barrels and 
boxes along the sidewalks, or thrown at random in the street. 
The Croton water and the house slops flowed into the gutters 
and mixed with the refuse and excrementitious matters from 



254 MORTALITY OF YOUNG CHILDREN IN CITIES. 

the tables and bed-chambers of the houses, while the interior 
of some of the houses and the spaces around them were in a 
similar filthy state. There was no Health Board at that time 
to enforce sanitary regulations, and any attempt to abate the 
nuisance of a filthy street in the absence of a sewer, and with 
the presence of a large and ignorant population, could be only 
partially successful. Consequently this street, with gutters 
constantly wet and containing decaying organic matter, was, 
during the hot months, one of the sickliest in the district 
which was assigned to me. The noxious gases emanating 
from such a source told fearfully on the general health, and a 
house-to-house visitation revealed the fact that diarrhoea was 
extensively prevailing among the infants thus exposed, and 
was a common cause of death during July and August. In 
another locality, occupied bj tripe dealers and a low class of 
butchers, who carried on fat and bone boiling at night, the 
air was so foul after dark that the peculiar impurity which 
tainted it I could distinctly notice in the taste for a consider- 
able time after a nightly visit. In the street where these 
nuisances existed, and in adjacent streets, a choleriform diar- 
rhoea was most destructive to infantile life. 

It is impossible to isolate and determine all the deleteri- 
ous gases of which the atmosphere of a city is composed, but 
this we know, that in streets which are not properly cleaned 
of refuse matter and in and around dwellings occupied by the 
destitute and degraded who disregard sanitary laws, the air 
becomes so foul during the hot months, when chemical changes 
are most active, as to be quite perceptible and offensive to the 
visitor. The common practice of watering streets which are 
dirty only adds to their unwholesomeness, for organic matter, 
whether in masses or triturated to powder by passing vehicles, 
is comparatively harmless when dry, but yields poisonous 
gases in abundance when moist and undergoing decomposi- 
tion. 

The amount of carbonic acid present in the air is regarded 
as a pretty correct test of the degree of its impurity. This 
gas is always present in the atmosphere, but when it exists 



MORTALITY OF YOUNG CHILDREN IN CITIES. 255 

in abnormal quantity it is associated with other poisonous 
gases, generally in quantities proportionate to its own, but 
which cannot be so readily isolated. Its quantity is always 
greater in the city than in the country, and in badly ventilated 
dwellings and public halls it frequently accumulates so as to 
be decidedly hurtful to those who respire it. Pure air, it is 
estimated, contains three to four parts by measure of carbonic 
acid in 10,000 of air, but Pettenkofer found 72 parts in a 
school-room two hours after the school was convened, and W. 
R. Nichols found 32 parts of the gas in 10,000 in a room 
which had been occupied by a Sunday-school for one and a 
half hours, while Baring discovered 120 parts in the rooms of 
a Volks-schulen. Now, it is admitted that carbonic acid may 
be largely increased in an atmosphere otherwise pure without 
causing serious consequences, but if this increase is from res- 
piration, cutaneous exhalation, and from decomposition of or- 
ganic matter, the carbonic acid is associated with other gases 
which are exceedingly poisonous. Pettenkofer remarks, and 
those who have investigated the subject agree in the general 
statement, " Air is bad and improper for continuous use when 
it contains in consequence of respiration and perspiration 
more than one part of CO 2 in 1,000, and a good air for cham- 
bers in which a person may remain for a long time in a state 
of health and comfort contains no more than .... seven 
parts in 10,000." The gases which are found with carbonic 
acid in occupied rooms have been enumerated by Parkes as 
follows : carburetted hydrogen, sulphurous acid, sulphuric 
acid, sulphuretted hydrogen, phosphuretted hydrogen, and 
ammoniacal vapors. 

In addition to these gases, which it will be perceived are 
very detrimental to animal life, the air contains motes of or- 
ganic matter, often in considerable quantity, as every one has 
noticed by viewing a sunbeam in a darkened room. Among 
these motes in an occupied room, the microscope discovers 
vegetable debris and various animal substances, as fragments 
of epidermic cells. Eulenberg discovered many animal and 
vegetable fragments and forms in the air, which he examined, 



256 MORTALITY OF YOUNG CHILDREN IN CITIES. 

some of them evidently having been wafted from long dis- 
tances. The air of the city contains a vastly greater quantity 
of these organic particles than the air of the country, as is 
evident from the dust, which is incessantly settling on furni- 
ture, and the dirt which is seen in neglected and unfrequented 
streets and lanes in the course of a few weeks. 

These many impurities, solid and gaseous, in the air of the 
city, together with the countless monads, vibriones, and bac- 
teria, just visible under high powers of the microscope, which 
spring into existence wherever decomposition is going on, 
afford sufficient explanation of the greater insalubrity of the 
city than of the country. Precisely in what way impurities 
in the air cause infantile diarrhoea is not known, though there 
are so many striking examples of the fact. Murchison states 
that twenty out of twenty-five boys in a school-room were 
affected with vomiting and purging from inhaling the effluvia 
from the contents of an old drain near the play-room. Per- 
haps the gases form certain combinations in the system which 
are purgative. Sulphuretted hydrogen, one of the most poi- 
sonous of these gases, is believed by those who have investi- 
gated the subject, to be changed into sulphuric acid in the 
air, and we know that this acid, if it unite with a potassium 
or sodium base, forms a purgative salt. 

Another important cause of the summer diarrhoea is the 
diet. A large proportion of those who every year fall victims 
to this malady would doubtless escape if the feeding were 
exactly proper. The following facts relating to this subject 
are substantiated by the experiences of each summer : In- 
fants weaned before the proper time are very liable to the 
summer diarrhoea, and the younger the infant thus artificially 
fed, the greater the liability. In New York a large propor- 
tion of the infants, under the age of six months, when the 
warm weather begins, if deprived of the breast milk, take the 
diarrhoea, and unless removed to the pure air of the country, 
where also fresher and better cow's milk can be obtained, 
perish. Aware of these facts, the managers of the infant and 
foundling asylums employ, so far as possible, wet-nursing for 



MORTALITY OF YOUNG CHILDREN IN CITIES. 257 

the young infants in these institutions, although it greatly 
increases the expense. Before the establishment of the Health 
Board in New York, when the air in and around the city 
was much more foul than at present, from the common disre- 
gard of sanitary laws, it was seldom that an artificially fed 
infant under the age of six or even ten months, residing 
within the city limits, escaped the summer diarrhoea. So 
fatal was this malady among bottle-fed infants in those days, 
when both atmospheric and dietetic causes were operative, 
in a high degree, that when I was appointed physician to the 
foundlings, about fifteen years since, I found it the common 
belief among the nurses and others, that all of them would 
sooner or later die. One was pointed out as a curiosity, since 
it had been several months in the institution, and was still 
alive. Such mortality was remarkable, for the foundlings of 
the city at that time exceeded one thousand annually. They 
were consigned to the care of the pauper women in the 
almshouse, who were mostly old, infirm, and filthy in their 
habits and apparel. Their beds, in which the foundlings 
were also placed, were seldom clean and properly aired, or 
washed, and under the beds were various garments and uten- 
sils which they had brought with them, as their possessions, 
from their miserable abodes in the city. With such sur- 
roundings the air which these infants breathed night and day 
was obviously totally unfit, while the diet was not less unsuit- 
able, for it was prepared by these degraded women from such 
milk and farinaceous food as the Commissioners of Charities 
furnished the almshouse. The common disease of these found- 
lings was diarrhoea, and the cause of the frightful loss of life 
was obviously both dietetic and atmospheric. 

Such waste of life was the legitimate result of the condi- 
tions ; for it occurred under a law of general applicability, 
that whenever the diet is improper and the air foul, infants 
pine away and die. What occurred with these foundlings is 
repeated every summer in the domicils of the city poor, when- 
ever infants are improperly fed, and the air which they breathe 
is loaded with poisonous gases, produced by over-crowding or 
17 



258 MORTALITY OF YOUNG CHILDREN IN CITIES. 

the prolonged action of the atmospheric heat on the decaying 
organic substances. 

Dietetic errors by which diarrhoea is produced, and if they 
are repeated intestinal catarrh results, are numerous. The 
reader is referred to the chapter relating to diet, for a state- 
ment of the kind and quantity of food which is suitable for 
different ages in infancy and childhood, departure from which 
is apt to cause indigestion and diarrhoea, and therefore to act 
as a potent cause of the malady which we are now consider- 
ing. 

But there is one dietetic cause of infantile diarrhoea oper- 
ative not only in the hot months, but at other times also, to 
which I wish to call attention. The late Dr. James Jackson, 
of Boston, pointed out the fact that too frequent and too pro- 
longed nursing, even when there is no fault in the milk, is a 
common cause of diarrhoea. Infants sometimes overnurse, 
and they may or may not vomit the surplus food. If they do 
not, the portion of the food which is not digested undergoes 
fermentative changes, becomes an irritant, and causes green 
and too frequent stools, which contain particles of undigested 
casein, and other ingredients of milk. If such infants fret, as 
they often do from indigestion, they are applied still more 
frequently to the breast. Gases and acids form in the 
stomach and intestines, and in consequence of the irritation 
thus produced, intestinal catarrh may result. Too frequent 
feeding with artificial food often produces the same result. 

In these various ways dietetic errors operate as the second 
factor in the causation of the summer diarrhoea, and they are 
not infrequently the immediate exciting cause. Having now 
considered the nature and aetiology of this malady, we are 
better prepared to consider by what measures its frequency 
can be diminished and its severity mitigated. 

It is evident from the above facts, that measures designed 
to diminish the severity and frequency of the summer diar- 
rhoea must be two fold : namely, such as provide' pure air, 
and secondly, the use of the best possible diet. 

The modes in which pure air can be obtained are various. 



MORTALITY OF YOUNG CHILDREN IN CITIES. 259 

Since, in recent times more attention has been given to sani- 
tary requirements, and the large cities have their Health 
Boards, most of the glaring nuisances which formerly poi- 
soned the air have been removed, and a corresponding decrease 
in the death-rate has been effected. Still in populous cities, 
even with vigilant police and Health Boards and strict sani- 
tary regulations, it is difficult to obtain that purity of the air 
which is required to produce the maximum degree of health 
and vigor in children during the summer months, and dimin- 
ish to the minimum the atmospheric cause of the diarrhoeal 
maladies. Children, even young infants unable to walk, 
realize the benefit obtained from fresh air, and are always 
more cheerful and contented when out-door during the hot sea- 
son than within-door, so that nurses have learnt that a quick 
and sure way to quiet a child made fretful by the heat and 
the close air of the house is to take it outside. This has the 
double advantage of giving it purer air, and of allowing the 
apartments to be thoroughly ventilated during its absence. 
The common practice in the cities of carrying children to the 
parks, of taking them on excursions by railway or boat, 
always has a salutary effect on those who are sick with the 
summer diarrhcea if they are not too weak, as well as upon 
those who without actual disease are languid, fretful, and 
with poor appetite, from the depressing influence of the 
warm weather. Observing this beneficial effect of pure air 
upon sick children in the hot months, benevolent people of 
New York have established a floating hospital, which three 
times each week, from June to September, carries sick children 
of the poor, who have no contagious diseases, on long excur- 
sions down the bay or up the rivers. The result has been so 
good that it is probable that this mode of aiding the poor will 
be continued during future summers. 

Now the method which we see practiced each day by 
mothers who carry their sick children into the shaded streets, 
or parks, or on excursions, lasting from morning till evening, 
with excellent results, indicates the way in which pure air 
should be provided on a more extensive scale, and therefore 



260 MORTALITY OF YOUNG CHILDREN IN CITIES. 

with greater result in saving life. If a large number of 
children, all, indeed, who urgently require purity of air to 
protect them from the sickness which we have described in 
the foregoing pages, could remain in the country during the 
period of greatest atmospheric heat, much good would accrue. 
Removed entirely from the operation of one of the chief 
causes of the disease which we have been considering, the 
effect would be to render the symptoms milder of those already 
sick, and to lessen the danger of contracting the malady on 
the part of those who might not yet be affected. The re- 
moval of children, even the youngest infants, with their at- 
tendants, in the morning and their return in the evening, 
seems quite feasible, but those sick with diarrhoeal maladies 
will often need longer and more quiet sojourn in the country 
than could be had by a morning removal to it and an even- 
ing return to the city. For such the Sanitarium will be in- 
valuable, where the benefits of country residence can be 
obtained both night and day as long as may be deemed nec- 
essary. The night air of a city is more impure than that 
of the day-time, for vegetation absorbs and appropriates by 
day, but not by night, to a great extent those deleterious 
gases of animal origin, the effects of which have been de- 
scribed in foregoing pages. Hence critical cases of the diar- 
rhoea should be kept entirely away from the city as long as 
their state involves danger. Those who enter the Sanitarium 
with infants seriously sick with the summer disease should 
expect to remain there till cooler weather or abatement of 
the symptoms occurs. The facilities for obtaining pure and 
fresh milk at the sanitarium, from its rural location, will also 
greatly increase its advantages as a place of resort for chil- 
dren whose ailments pertain to the digestive apparatus. Par- 
ticulars in regard to the proper dietetic treatment of cases will 
be found in the pages relating to diet. 

ACUTE INFECTIOUS DISEASES. 
A considerable number of preventable diseases occur, which 
increase the mortality of infancy and childhood in all seasons 



MORTALITY OF YOUNG CHILDREN IN CITIES. 261 

of the year alike, and they must not be overlooked in the 
adoption of measures designed to diminish the death-rate in 
the summer. I refer to the acute infectious diseases which 
children contract from each other, and which are therefore 
more prevalent and fatal in the cities than in the country, 
where the population is more scattered. 

Small-pox, there is good reason to think, will, at a day not 
far distant, be eradicated from civilized communities by gen- 
eral vaccination. It is now virtually eradicated from our 
largest city (New York) through the efficient action of the 
local authorities, in compelling the vaccination of all children 
in the schools and tenement houses, but there is no such 
prevention of scarlet fever, measles, diphtheria, and whooping- 
cough, and they therefore largely increase the aggregate of 
deaths in all our cities. The treatment of cases of these mal- 
adies must obviously be left for the most part to the family 
physicians, but much can be done to check their spread by as- 
sociated action, having the confidence of the community, with 
the requisite facilities. The one palpable way of effecting 
this is by strict isolation of the well from the sick as soon as 
the first symptoms of disease appear. It is difficult to ac- 
complish this, as families are ordinarily situated in the city, 
without extraneous help, and the physician is compelled to 
witness the spread of a fatal malady from child to child, 
which might have been prevented. Families even under the 
tie of relationship are reluctant to receive in their midst 
children who have been exposed to an infectious disease and 
may at any moment sicken with it and communicate it to 
others. There is need, daily felt in our cities, of a place of 
resort to which children who are well, and who reside in a 
house where a contagious disease breaks out, can be removed 
and kept till the case terminates, and the house by disinfec- 
tion is rendered safe for their return. But a difficulty arises 
with any institution or association that has the care of chil- 
dren, in providing for this want, since a child exposed to one 
of the ordinary infectious maladies, and liable at any mo- 
ment to have it himself, should not mingle with other chil- 



262 MORTALITY OF YOUNG CHILDREN IN CITIES. 

dren, inasmuch as the specific poison may be in his clothing 
or upon his person, and thus may infect those with whom he 
comes in contact, or he may himself at any moment exhibit 
symptoms, and become the source of contagion. 

Now in solving this problem, how to prevent the spread of 
the infectious diseases, it is evident that any child who is to 
mingle with other children in receiving the benefits of the 
Thomas Wilson Association should carry with him the cer- 
tificate of the family physician, stating that he has no con- 
tagious malady, as is done in case of the Floating Hospital 
in New ~iork. To meet the emergencies which will arise in 
the city, it seems to me that a cottage sufficiently isolated 
should be provided in or near the city, to which the well chil- 
dren could be immediately taken as soon as an outbreak of 
an infectious malady occurred ; and if any one thus removed 
showed indubitable signs of having contracted it, he could be 
immediately returned home. If after two weeks' isolation 
they exhibit no symptoms they could be removed farther, if 
thought best, and mingle with other children. 

The specific principles of the infectious diseases are so 
subtle, and spread so insidiously, that it is difficult for any 
institution where children are received from a city to remain 
entirely and permanently free from them. With all the 
precautions which have been employed, the Xew York insti- 
tutions are now and then visited by measles, scarlet fever, 
diphtheria, and whooping-cough. Therefore the Sanitarium 
would require a cottage conveniently situated, but sufficiently 
isolated, to which cases that presented suspicious appearances 
could be at once transferred, and three or four additional cot- 
tages, isolated from each other, for those that presented clear 
and indubitable symptoms of the common infectious maladies. 
This subject will be more fully considered in Part II. 

In this connection it may be well to allude to important 
facts in reference to the infectious diseases of children, which 
should not be lost sight of in determining the plan for a quar- 
antine building. They are very contagious to a short distance, 
and the specific principles of scarlet fever and diphtheria ex- 
hibit great tenacity in adhering to a room or furniture. 



MORTALITY OF YOUNG CHILDREN IN CITIES. 263 



PART II. 

CARE OF THE CHILDREN OF THE POOR IN THEIR HOMES, IN 
HOSPITAL, AND IN A SANITARIUM. 

The conditions under which sick children of the poor of 
cities may best receive medical care are various. In the first 
place, by far the larger number should be treated at their 
homes. Nearly all acute non-infectious diseases should re- 
main at home under the care of the mother and family phy- 
sician. Such diseases do not bear transportation well at an 
early stage ; nor is it necessary for their proper management 
that they should have other care and nursing than that 
which may be obtained at home. Secondly, acute infectious 
diseases should be treated at home, if they can be properly 
isolated ; but if this is impossible, it may be best sometimes 
to remove them to a hospital ward. But it should be re- 
membered that it is hazardous to remove the eruptive dis- 
eases from one building to another without precautions against 
taking cold ; and their distant removal during the eruptive 
stage is never proper except under very unusual circum- 
stances. Thirdly, certain cases, as surgical accidents, diseases 
requiring operations, etc., are ordinarily better treated in the 
hospital than at home. Fourthly, among the poor, cases of 
maladies of different kinds will always be found, which, on 
account of impoverishment of the blood and reduced state of 
the general health, cannot be so successfully treated at home, 
on account of the anti-hygienic surroundings, as in the coun- 
try, either at the sea-shore or in the mountains. For such 
persons sanitaria are very useful. 

It follows, that a scheme for the care of the sick children 
of the poor of a city, which adequately meets all the require- 
ments of this class, must comprehend suitable provision for 
them : first, in their homes ; second, in hospital ; third, in a 
sanitarium. This Part will, therefore, be devoted to the de- 
velopment of a plan which, in its details, comprises the three- 
fold conditions under which the children of the poor of a city 
may best receive hygienic and medical care. 



264 MORTALITY OF YOUNG CHILDREN IN CITIES. 

Before entering upon the formal discussion of special top- 
ics it is important to consider what form of central organiza- 
tion will be best adapted to give stability, unity, and force to 
the proposed institution, which is to be the pioneer in a new 
field of charity. 

1st. It should have all the conditions of permanency fully 
established at the very outset. No great charity can be suc- 
cessful in the highest degree if it have no other palpable 
existence than that given to it by a will, or by articles of 
agreement and a board of managers or trustees. It must 
have a local habitation and a name as a public institution 
where all its work centres, and from which its influences pro- 
ceed. But there are other reasons for the establishment of a 
central office. 

2d. There must be a school for training nurses to perform 
the duties which will be required of them as visitors among 
the sick poor, or while serving in the hospital, or at the san- 
itarium. This service will require of the visitor and nurse 
especial knowledge, which can be satisfactorily obtained only 
by systematic training. Nowhere can this school be so well 
and thoroughly managed as at the central building or office. 

3d. There must also be a common residence for nurses, 
where they will be under constant discipline, and this can 
best be provided for at the main building. 

4th. A plan for gratuitous medical relief in a city requires 
a central office where all of the work is systematized and 
supervised. This central office will thus give unity to the 
entire work of the institution, however extended or diversi- 
fied it may be. 

The Home. — The central office should be known as " The 
Home," or by some other kindred title of equal significance. 
In its establishment the following points should be consid- 
ered : — 

(1.) The location should be such as to render the Home 
conveniently accessible to all parts of the poor districts of the 
city. The site should combine all possible conditions of health, 
as elevation, good drainage and sewerage, and open spaces 
around it, as parks. 



MORTALITY OF YOUNG CHILDREN LN CITIES. 265 

(2.) The building should be constructed on a plan which 
will give the largest southwesterly exposure, both on account 
of the sun, and of the prevailing winds. 

Its service should be arranged as follows : — 

(1.) The matron should be a skilled nurse, educated to such 
duties, and trained to their performance, by long experience. 
She should have the general supervision not only of the 
Home, but of every branch of the work. 

(2.) The training school should be organized for the pur- 
pose of giving instruction in the care of the sick, in hygiene, 
and especially in the relations of domestic life among the poor 
of cities to the diseases of childhood. 

(3.) The nurses, when under training, should be assistants 
to the other nurses who have completed their education and 
have received their proper testimonials. Provision must be 
made for the trained nurses, and for a lecture room. Every 
nurse should have her own private room with all necessary 
conveniences. The lecture room would be small, and for this 
purpose adjoining rooms might be thrown into one on an oc- 
casion. 

I. Sanitary Care and Treatment of Children and their Dis- 
eases in their Homes. 

Although the care and treatment of sick children in hos- 
pital and sanitarium are important, it cannot be denied that, 
considered as a scheme of benevolence, the largest benefits 
will result from the efforts put forth to secure the proper pro- 
vision for their care and treatment at home. For by far the 
larger number of cases of sickness among the children of the 
poor must, of necessity, be treated at home. If indeed we 
exclude surgical accidents, acute infectious diseases, and chronic 
affections, which require other hygienic conditions than can 
be secured in the family, the remaining infantile diseases 
would be better attended at home, provided that suitable pro- 
vision were made for their care. Again, it may commonly 
happen that the mother cannot leave home, though her per- 
sonal attention, as in the case of an infant, is absolutely es- 
sential to its proper treatment. 



266 MORTALITY OF YOUNG CHILDREN IN CITIES. 

In the second place, the indirect benefits which the parents 
derive from the care of their own sick children, when aided 
and advised by a skilled physician and competent nurse, are 
of the greatest importance. It is therefore in this branch of 
the subject that we shall consider " the most practicable 
means of lessening the risks and dangers incident to children 
exposed to the heated and impure atmosphere of a large city, 
during the summer months, and also as to the best methods 
of extending a general knowledge of simple hygienic rules for 
the treatment of sick children at home among the poorer 
classes." 

In any well matured plan for the care of the sick poor in 
their homes, two things are requisite, namely : (1.) medical at- 
tendance, and (2.) skilled nursing. Neither of these important 
duties should be left to the discretion of the family to pro- 
vide. In this plan something more should be contemplated 
in the functions of both physician and nurse than is ordi- 
narily intended and performed. They should be practical 
teachers of household hygiene, and should illustrate and en- 
force their lessons by daily examples. They should not only 
teach the art of caring for the sick, but should take advantage 
of their special duties in the family to aid, by advice and per- 
sonal attention, in improving the condition of the home, and 
the methods of administering its affairs. 

(1.) The Medical Service. The method of providing medi- 
cal attendance for the poor of a city, is through the agency 
of the dispensary. This institution is organized so as to 
have a dispensary and district service. The in-door dispen- 
sary service is entirely devoted to the sick poor who can 
leave their homes and visit the dispensary, and who do not 
require special attention. All of the minor ailments of chil- 
dren may thus be successfully treated. The district service 
is designed to supply medical attendance to the sick who 
cannot leave their homes. It is performed by a separate class 
of physicians, who attend to the sick regularly, as in pri- 
vate practice. The medicines are all obtained at the dispen- 
sary. 



MORTALITY OF YOUNG CHILDREN IN CITIES. 267 

The dispensary system is now recognized as the best or- 
ganized method of dispensing medical relief to the poor. But 
to meet the full requirements of the scheme proposed in this 
paper, the dispensary system should be organized on the im- 
proved plan, which requires that the dispensaries should be 
self -supporting. To effect this object a small sum is charged 
for medical attendance and medicines. This small tax, in- 
stead of being a burden to the poor, is generously paid, and 
always proves very useful. It tends to create a feeling of in- 
dependence in the recipient of medical care and medicines, 
and thus prevents the pauperizing influence of gratuitous serv- 
ices rendered in the interests of charity. 

The general dispensary consists of a building centrally lo- 
cated, as regards the district to be served, with apartments 
for the classes of diseases to be treated, and for the resident 
officer and apothecary. The medical attendants are divided 
into two classes, namely, the attending and visiting physicians. 
The attending physicians attend daily at the dispensary, at 
the hours fixed for their individual classes, and prescribe for 
those who are able to visit the institution. 

The visiting or district physicians have certain areas of the 
general district assigned to them, and they visit those patients 
who have been registered at the dispensary as unable to leave 
their homes. In this manner all the sick poor of a city may 
receive medical care and attendance with but little expendi- 
ture of money, and if a small charge is made for medicines 
and attendance, the dispensary readily becomes self-support- 
ing. 

It is quite impossible to organize a system of gratuitous 
medical care and attendance upon the sick poor of a city more 
complete in all its details than that furnished by the dispen- 
sary. Every person who asks or seeks medical care receives 
prompt attention from skilled physicians, who, in turn, have 
ample means of determining their social condition and real 
necessities. 

If a dispensary system exist, as generally happens in large 
cities, it may be made available for the purposes which we 



268 MORTALITY OF YOUNG CHILDREN IN CITIES. 

now contemplate, and thus the expense and care of organizing 
a new system may be prevented. 

If, however, the general dispensary do not exist, or be 
not available, a system of information and medical care should 
be organized which will meet as nearly as possible the same 
conditions. The " Home " may now become the centre of 
this service. The area to be supplied with relief should be 
divided into districts, each one being of such size and form as 
will economize the time and efforts of the district visitor. To 
each district a physician, living if possible in the district, 
should be selected, whose duty it shall be to act in the capaci- 
ty of a district physician. Young men very cheerfully volun- 
teer their services for this work, and, with care, a thoroughly 
competent class may be secured. The duty of the district 
physician should be to visit the sick on call, as in the ordi- 
nary dispensary. He may also be one of the attending physi- 
cians at the other branches of the institution, a position which 
young physicians seek, and which they regard as a decided 
step of advancement in their profession. The record of the 
cases which he is to visit should be daily sent to him at his 
office, and his returns of visits should be daily made, in writ- 
ing, in the register. 

2. Skilled Nursing. To each medical district should be 
assigned as many women visitors as may be necessary to sup- 
ply one visitor to every fifty families. The women district 
visitors should be trained nurses from the "Home." Their 
duties should be (a.) The prevention of sickness in the fam- 
ilies of the poor, (5.) The care of sick children, under the 
direction of the district physician. 

(a.) The prevention of sickness in a family will require 
more or less frequent personal visits of the district visitor. 
The frequency of these visits must depend on the intelligence, 
moral tone, and temper of each individual household. Many 
families will receive the visitor in the most cordial manner, 
and quickly respond to every suggestion. Such families will 
require but little personal attention, for whatever reform in 
household management is desired and enforced by the visitor 



MORTALITY OF YOUNG CHILDREN IN CITIES. 269 

will be commenced and continued without her constant super- 
vision. These families will also make stated reports, if re- 
quested, of their condition, and especially of the occurrence of 
cases of sickness. 

A smaller number of families will respond less promptly to 
the wishes of the visitor, but by more frequent visits at first, 
and a closer acquaintance of the visitor with the parents, and 
especially with the mother, confidence is gradually established, 
and in time these families closely approximate the former. 
There still remain in every city community certain families 
closely allied to the vagrant classes. They are, indeed, so 
nearly on the border line, that any slight disturbing cause 
breaks the feeble domestic ties which hold them together, and 
precipitates them into hopeless vagrancy. Sickness, acute and 
wasting, is never absent from these families, and death is a 
familiar visitor. Few children, comparatively, attain the fifth 
year, and if by chance they grow to manhood or womanhood, 
they find decrepitude at twenty, and death with all the condi- 
tions of old age at thirty to forty-five. Hapless and hopeless 
as these families seem to be, it is in the efforts to elevate and 
improve them that modern philanthropy has won its greatest 
victories. As long as the domestic ties are sufficiently strong 
to maintain the semblance of family individuality, this class 
of the poor of cities may be reclaimed. More often it will be 
found that the parents have fallen from a better estate through 
misfortunes or vices, and it only requires a sympathizing friend 
with hopeful and encouraging words to awaken old emotions 
and aspirations for a better condition in life. It is true that 
the progress which such families make in improvement is 
often painfully and discouragingly slow ; but that fact should 
not dampen the ardor or weaken the determination of true 
philanthropy. One such family raised to a better life by such 
aid as may be given by the Thomas Wilson Association will 
prevent more sickness among children, and be more far-reach- 
ing in its results, than the care of a score of children of the 
better class. 

The object of the ordinary visit should be to secure such 



270 MORTALITY OF YOUNG CHILDREN IN CITIES. 

relations between the visitor and her families that a mutual 
and permanent interest would be established between the two 
parties. The district visitor should soon become familiar with 
the peculiarities of her families. She should silently note at 
each visit the condition of the apartments as to cleanliness, 
the orderly arrangement of the furniture, and the condition of 
the clothes. She should observe the kind of food, and unob- 
trusively inquire as to the methods of cooking. Gradually, as 
she becomes more and more ingratiated into the affections of 
the family, she would learn its secret history, its moral, relig- 
ious, and social tendencies, and everything that directly or 
indirectly affected its healthful development. As she acquires 
this knowledge and wins the confidence of the famity, she in 
turn imparts such instruction on subjects relating to the hy- 
gienic management of the children as she sees is needful and 
timely. Little by little, under this training, the habits of the 
family change. Improvement occurs in the various branches 
of its limited yet multifarious duties. Order gradually suc- 
ceeds to disorder in the arrangement and management of the 
house ; cleanliness appears on the floor and walls, in the cloth- 
ing and bedding, and in the persons of the parents and chil- 
dren. As a legitimate consequence of the improved hygiene, 
a better state of health succeeds. Apathy and long disre- 
gard of sanitary laws, the result of ignorance and poverty, is 
replaced, under the sympathy and encouragement of the vis- 
itor, by a strong desire for improvement in the mode of life. 
The children, formerly repulsive from filth and external evi- 
dences of disease, are now clean and tidy, and the ruddiness 
of health appears in the features. This is not an over- 
wrought picture, nor a fancy sketch having little foundation 
in reality. The mass of people, however low in society, desire 
improvement, and the strong love of the mother for her off- 
spring will prompt her to make many exertions and sacrifices 
in the humblest sphere, and with the most limited resources, 
that her children may have health and comfort, of which she 
perhaps has been deprived. 

That visitors among the poor, actuated by the right mo- 



MORTALITY OF YOUNG CHILDREN IN CITIES. 271 

tives, and having the authority of an appointment from a 
legally constituted board, do have a decided influence in im- 
proving the physical condition of families, is abundantly 
shown by our experiences in New York. For, since the first 
sanitary inspectors, a body of young physicians, were sent out 
by the old Citizens' Association some fifteen years ago, to visit 
all the tenement houses and report their condition, the great 
mass of poor families are certainly much more cleanly in their 
habits than formerly. They welcomed this effort made in 
their behalf, which has been continued under the Health Board, 
and through the visits of city missionaries. Another fact in 
the same direction has also often been noticed, namely, that 
wives and mothers who have been servants in families, and 
upon whom their old mistresses occasionally call, and in whom 
they thus manifest an interest, have clean and tidy apart- 
ments and apparel, though living on the scantiest income. 

Not only would diminution in the amount of sickness, and 
in the death-rate, result from the visits of conscientious, intel- 
ligent, and sympathetic women, in consequence of improve- 
ment in the hygienic condition of families, but their labors 
would be beneficial in another important way. Maladies are 
more easily controlled, and are rendered milder in a large pro- 
portion of instances, if detected in their incipiency, and if the 
proper remedies are then applied. Now it would be entirely 
practicable for a trained visitor to anticipate some diseases, 
and to detect the approach of others, in time to prevent the 
attack, or make it milder. The ravages of Asiatic cholera 
have been greatly mitigated by visitors, who went from house 
to house, and impressed upon the inmates the importance of 
checking every diarrhceal attack however mild. Very many 
lives might be saved every summer in our cities, if mothers 
could be informed that the diarrhoea of their infants is not 
conservative on account of dentition, and that what they think 
lightly of is the beginning of a most fatal malady which will 
inevitably bring desolation to their homes in a few weeks, if 
it be not checked. 

Whenever unusually severe cases occur, requiring superior 



272 MORTALITY OF YOUNG CHILDREN IN CITIES. 

nursing, the woman visitor might frequently become the 
nurse, under the direction of the physician, though it might 
be quite impossible, as a rule, for the nurse to be in constant 
attendance on the sick. Her attendance would in general 
supplement that of the physician. 

The effect of such care of the sick, both upon the sick and 
the family, cannot be fully computed. Experience shows, 
that among the poor, sick in their homes, receiving the care 
of a physician, and the nursing of the family, simple diseases 
not infrequently become severe and complicated, from negli- 
gence or other cause, a result which the presence of a skilled 
nurse might have prevented. But when medical skill is aided 
by expert nursing in the homes of the poor, the most severe 
diseases usually run quite as favorable a course as in the 
homes of the wealthy. Even the aid of diet kitchens, which 
furnish selected and well prepared food to the sick poor, tends 
to diminish, it is believed, the mortality among this class, in 
the dispensary districts of New York. 

The influence of the presence and services of the nurse in 
the homes of the sick poor, during severe sickness, is as, has 
been intimated, not limited to the welfare of the patient, but 
is felt by all and impresses itself upon the future life of the 
family. There is a discipline of the whole household, which 
under the circumstances, is lasting. Whatever may be the 
special temperament of the members of the family, all are 
rendered peculiarly susceptible, by anxiety, to the impressions 
which the acts of a patient, intelligent, sympathizing nurse 
will make. Cleanliness and ventilation are now, perhaps, first 
enforced, disinfection is now practiced, and foods are carefully 
selected and prepared. In a word, all the simple rules by 
which the apartments of the sick are rendered healthy, cloth- 
ing made clean and wholesome, food cooked so as to be di- 
gestible, are now silently but effectively taught. It is 
scarcely too much to say that when sickness among the poor 
results in the elevation of the family in the scale of healthy 
living, it is a blessing rather than a curse. 



MORTALITY OF YOUNG CHILDREN IN CITIES. 273 

II. Sanitary Care and Treatment of Children and their Dis- 
eases in Hospital. 

The necessity of hospital care of children suffering from 
surgical accidents and operations, and from chronic suppura- 
tive diseases, has been recognized as a part of medical chari- 
ties devoted to the poor of cities. It is impossible to treat 
this class of patients efficiently in their homes, though the 
surgical skill and nursing be of the highest quality. There 
will always be a want of proper appliances, of requisite floor 
space, of suitable bed and bedding, and of many other con- 
ditions essential to their successful treatment. It is found, 
therefore, that where hospital care is provided for these cases, 
lives are saved which would otherwise have been lost, a vast 
amount of suffering is prevented by the better methods of 
treatment and the diminished length of time required, and in- 
validing deformities of limbs cured that would have pauper- 
ized the unfortunate subjects of hereditary diseases. 

The child's hospital may be a very simple and inexpensive 
branch of the service. It should be located at the " Home," 
and, if the surroundings are favorable, should be an indepen- 
dent building, one story in height, with wards properly ex- 
posed to the sun and air. The wards should be two or more 
in number to accommodate the sexes. The general details of 
construction should make the hospital a model of good venti- 
lation and heating. If it is not practicable to build a new 
structure, wards may be constructed in the Home which will 
serve the purpose, though not as suitable as in a well ar- 
ranged isolated building. The rooms selected should be on 
the second floor, to avoid dampness, and to secure a free flow 
of external air, and escape of the emanations of the living 
rooms. If the building have a southern extension, this portion 
may be made available. In the arrangement of rooms for 
wards, all the conditions for the health of the inmates should 
be even more carefully studied and provided for, than in the 
separate hospital, because unheal thful conditions are more 
numerous and difficult to meet. 

18 



274 MORTALITY OF YOUNG CHILDREN IN CITIES. 

The matron of the Home becomes the matron of the hos- 
pital, and the trained visitors the nurses. The surgical and 
medical attendance would be gratuitously supplied by appoint- 
ment from the profession of the city. 

III. Sanitary Care and Treatment of Children and their Dis- 
eases in a Sanitarium. 

In the organization of a sanitarium it must be borne in 
mind that neither the donor nor trustees promise that it 
shall fulfill the conditions of a hospital. The primary motive 
of Mr. Wilson in establishing a sanitarium is given in his will 
as follows : " I have observed for many years with much con- 
cern, the great and alarming mortality which occurs each 
summer among young children deprived by misfortune of 
their parents of all opportunity for removal from the heated 
and fatal atmosphere of the city." He therefore gave to the 
corporation appointed to administer the funds bequeathed, 
the title of " The Thomas Wilson Sanitarium for Children of 
Baltimore City." The trustees " at their first meeting, pre- 
liminary to the formation of any definite plan of procedure," 
determined to correspond with persons " eminent for their 
success and experience in the treatment and care of sick chil- 
dren." In requesting essays or contributions from their cor- 
respondents, the trustees stated that they had " in mind the 
consideration of the best method of establishing a sanitarium 
(not a hospital but a summer retreat) for sick children." 
The trustees also desire an " opinion regarding the regula- 
tions suitable for receiving and administering medically and 
otherwise to those who shall be the proper subjects of their 
care, with suggestions as to the character of the buildings 
that may be requisite, their grouping or isolation, and how 
best to provide for mothers and nurses accompanying their 
children." 

From these statements it appears that the sanitarium should 
have a twofold plan in its organization : — 

(1.) " For well children among whom a great mortality 
occurs each summer, because they are deprived of all oppor- 



MORTALITY OF YOUNG CHILDREN IN CITIES. 275 

tunity for removal from the heated and fatal atmosphere of 
the city. 

(2.) " Provision for a summer retreat for sick children from 
the heat and unhealthfulness of the city." 

These two objects are so different, both in regard to the 
children to be relieved, and their special wants, that it neces- 
sitates the division of the sanitarium into two departments, 
one to be devoted to well and the other to sick children. Be- 
fore the plan can be projected for care of these two classes of 
beneficiaries in a sanitarium, an approximate estimate must 
be made of the number of persons to be provided with homes. 

Number of Well Children. It may, we think, be justly es- 
timated that of the annual average of 743 deaths of infants 
in Baltimore referred to in the prefatory note, at least 60 per 
cent, belonged to the families unable to remove " from the 
heated and fatal atmosphere of the city." Accepting this 
ratio as a basis of calculation, the number of deaths by heat 
of those who would properly become beneficiaries of this 
charity is about 450, or to make a more liberal provision we 
will allow 500. 

But this is by no means the actual number of well per- 
sons for whom provision must be made. Every child under 
one year of age, nursing its mother, must be accompanied by 
its parent and her other children too young to be separated 
from her care. On an average, it may be stated that one 
such child must be added to the list for every nursing moth- 
er's child. Orphan children and those fed by the bottle, will 
require only a nurse for two or three children. If we esti- 
mate the nurslings at 400, their attendants would be 800, and 
if the bottle-fed are 100, their attendants would be at least 
thirty. The total number of persons would be 1,200 of the 
former, and 180 of the latter, or a grand total of 1,330. 

But it is not necessary that each well child of the 500 
should remain at the retreat during the entire heated term or 
twelve weeks. On the contrary it may be estimated that an 
average residence of sixteen days during the hot months for 
each child will suffice to prevent the fatal effects of heat in 



276 MORTALITY OF YOUNG CHILDREN IN CITIES. 

the city. It is true that some children will require more time, 
bat others would require less, and the average may be fixed 
as above. 

From this statement we are able to fix the average popula- 
tion of this branch of the retreat during the three hot months 
at 100 children, the mothers and nurses at 100, and the addi- 
tional children at 100, making a total of 300 souls. 

Number of Sick Children. The annual average number 
of cases of sickness among the children of Baltimore, of five 
years or under, for the four years 1875, 1876, 1877, 1878, 
may be estimated at about 100,000. The estimate is based 
upon the calculation of Mr. Playfair that for every death in 
a community there have been 28 cases of sickness. To be 
more exact, the annual average death rate of children of that 
city during the four years mentioned was 3,494, which would 
give a total annual average of sickness of 97,832. If 90 per 
cent, of these cases were in part in better families, or not so 
severe but that convalescence followed without special after- 
treatment, there would still be not far from 8,000 cases of 
severe illness, requiring more than ordinary care during con- 
valescence. This number would be a monthly average of 
650 cases. It would be a safe estimate that of this number 
not more than 200 monthly would become beneficiaries of 
this sanitarium. For the purpose of this computation we will 
fix the number of sick children to be provided for at 200. 

Distribution of Children. In the distribution of the chil- 
dren and their attendants regard must be had to the fact, 
that the family relation of each group should be as far as 
possible maintained. In order to do this one hundred domi- 
ciles are to be provided, each having the conveniences neces- 
sary for domestic privacy and comfort of at least three per- 
sons ; namely, the mother and her two children. 

The arrangement of the individual homes so as to secure 
the best conditions for health, with economy in their con- 
struction and facility of administration, is not a difficult prob- 
lem when considered with reference to the objects to be ob- 
tained, the large tract of ground to be utilized, and the climate 



MORTALITY OF YOUNG CHILDREN IN CITIES. 211 

of the locality. The several questions which are to be deter- 
mined are as follows : — 

The Site and its Preparation. That portion of the grounds 
especially devoted to the residences of this colony should em- 
brace an area of at least twenty-five acres. It should have 
an elevation equal to and if practicable greater than the sur- 
rounding country, in order to secure the free flow of the air. 
It should have a south-southwestern surface-inclination in 
order to be well exposed to the prevailing winds and to the 
sunlight. If there is an opportunity to select soils, that should 
be preferred which is least retentive of water and even moist- 
ure, such as soils free from compact clay strata near the sur- 
face. Alluvial and sand formations are especially dry, and 
if rendered fertile by proper admixture of loam should be se- 
lected. Whatever the soil may be, deep drainage will be a 
necessary expedient to prevent the soil soakage during pro- 
tracted rains and even dampness at all times. 

The selection of shade trees and their arrangement on the 
grounds, while largely a subject for the skill and taste of the 
landscape architect, must still be subordinate to the sanitary 
conditions to be secured. The trees selected should, in part, 
be such varieties as have special medicinal properties which 
are diffusible in the air, as the aromatic trees and shrubs, or 
which purify the air by absorbing greedily deleterious miasm 
floating in it, as the linden, the maple. The selection should 
include trees and shrubs which flower successively during the 
summer. The shade should not be so dense as to make the 
ground damp, even in small areas as groves. Nor should the 
trees be grouped so as to obstruct the south-southwesterly 
and westerly winds. Arbors should be provided in which 
hammocks and swings can be suspended : shaded walks 
should be laid out with hedge rows at intervals so dense as to 
secure isolation and privacy. Fruit-trees should not be al- 
lowed on any grounds devoted to children. 

Fountains with spray, ponds through which fresh water 
constantly flows, and running streams, are desirable features 
of the landscape both for beauty and healthful purposes. 



278 MORTALITY OF YOUNG CHILDREN IN CITIES. 

The Administration Buildings and Domiciles. The admin- 
istration requires one building for offices, a second for the 
kitchen and dining halls, and a third for the laundry. The 
building for offices should be in the front portion of the 
grounds where it will be of easy access to those who visit the 
sanitarium, and conveniently located to the several branches 
of service. This building should be the residence of the su- 
perintendent, and should be constructed accordingly. The 
kitchen should be located on the northern part of the grounds, 
centrally as to the colonies, but quite beyond the limits of 
grounds occupied by the residents. 

In arranging dining-rooms, and in the distribution of food, 
it must be borne in mind that there will be two classes of per- 
sons to be provided: (1.) The bottle-fed, and those under five 
years of age accompanying their mothers. (2.) The mothers 
aiad nurses. The nursing infant does not enter into the ac- 
count. The first class are evidently to be chiefly supplied 
with good milk. This milk may be given out two or three 
times a da}^ on tickets issued to the mother or nurse, from 
the kitchen, or other more convenient depot, where it is kept 
in proper coolers, — the milk being taken to the domicile, 
where it is to be consumed. Older children, who require a 
miscellaneous diet, can accompany the mothers and nurses to 
the general table. The second class should dine at common 
tables located in the wings of the kitchen, or in separate din- 
ing-rooms adjoining the kitchen. 

The laundry should be located at a distance from the 
kitchen, still farther to the northward of the colonies, and in 
a wooded ravine, where all its outflowings will be from the 
occupied grounds, and to the leeward of the residences. If its 
sewerage is a part of the system provided for the entire 
grounds, the waters that flow from the laundry should enter 
the main at such point as will secure .its uses for flushing 
drains containing much excreta. 

Domiciles and their Arrangement. The domiciles for both 
branches of the sanitarium should be constructed chiefly of 
tenting cloth, but with substantial raised wooden floors, and 




>opif»g-cougft. 



Mumps. 




Scale of feet. 






MORTALITY OF YOUNG CHILDREN IN CITIES. 279 

ample materials for flies as a protection against the sun and 
rain, and every convenience for comfort should be provided. 
In order to accommodate families of various conditions, the 
tents must vary in size and form. Some families desire to 
live entirely isolated, others prefer to live in apartments im- 
mediately adjoining friends, and still others are willing to 
take rooms in a large apartment dwelling. The tents may be 
therefore assorted so as to accommodate one, two, three or 
more families. But in addition to tents for families there 
must be wards for well and sick children, having no parents, 
or who are under the charge of nurses. These wards should 
be arranged on a long axis running north and south, and 
should have not more than thirty beds each, fifteen on each 
side. Smaller tents for four to ten children, under the care 
of one nurse, should be provided in addition to two or three 
single, large wards. But there will always be some families 
of the well and sick, who should live in wooden structures, 
and hence it will be important that several cottages be con- 
structed. They may be single or two story buildings, and 
have apartments for four to ten families. In addition to these 
buildings, there should be a central one in each group, con- 
taining a long ward exclusively for children in charge of 
nurses. The grouping of these structures admits of an un- 
limited amount of taste and skill. It will suffice to say that 
the important fact to be kept in mind, and that which should 
dominate every plan, is purity of air for each individual. To 
this end the most important point to be considered, in placing 
the various structures, is to give ample ground space to each 
individual person. As a rule, not more than twenty-five per- 
sons should be placed on an acre. The position of tents, and 
other structures, with regard to each other should be such as 
to admit of free circulation of air, without violent draughts 
during storms. This will be principally accomplished by 
avoiding long straight avenues, and requiring, in pleasant 
weather, when the wind is light, the raising of the sides of 
the tents. The closure of tents during storms is a regulation 
readily enforced, because thereby the comfort of the occu- 
pants is best secured. 



280 MORTALITY OF YOUNG CHILDREN IN CITIES. 

Water Supply and Drainage. Among the most important 
conditions affecting the salubrity of the sanitarium is the sup- 
ply of pure water, and the rapid and complete removal of all 
sewage. Although these are questions to be finally deter- 
mined by the engineer and architect, it is proper to state : 
1st, that the supply of pure water should be so abundant as 
to meet every demand, whether for the uses of the colony, or 
the administration buildings, or for flushing ; and 2d, that the 
sewage will be most effectually disposed of by employing it 
as a fertilizer by sub-irrigation. If the flow of water cannot 
obtain sufficient head by natural means, machinery should be 
used which will give the requisite pressure upon all of the 
conduits so as to secure rapid and powerful currents. As a 
part of the system of sub-irrigation the "trough water-closet" 
affords the most effectual method of removing the excreta of 
people aggregated on the grounds of a sanitarium. When 
they are thoroughly cared for by a competent person, this 
closet has been found the simplest, cleanest, and most effec- 
tive method of disposing of excreta, of large populations of 
poor people, yet devised. The system of sub-irrigation with 
which the trough-closets should be connected consists of a 
number of lines of tile-pipe laid at a depth of twelve or more 
inches below the surface of the ground. Through these pipes 
the sewage is distributed underground over any desirable 
area, and becomes a valuable fertilizer, while it is in that 
process rendered innocuous. 

Cottages for the Reception of Acute Infectious Diseases. 
As stated in Part I., it is very difficult to prevent the out- 
break of contagious diseases from time to time, where any 
considerable number of children congregate. Therefore sepa- 
rate buildings or tents should be provided, at least one eighth 
of a mile away from the cottages and tents of the sanitarium, 
and to the leeward of the prevailing winds, to which every 
case that presents a suspicious appearance can be immedi- 
ately removed. Frequently the nature of an infectious dis- 
ease is not apparent until it has continued a day, or a part of 
a day, and often symptoms from some transient indisposition 



MORTALITY OF YOUNG CHILDREN IN CITIES. 281 

simulate closely those of an infections malady. Several hours 
or a day or two may be required to ascertain the exact char- 
acter of the affection ; for such cases a cottage for observa- 
tion seems indispensable. The stay of any one in this build- 
ing would be transient. Apart from it, and apart from each 
other, there should be three or four additional cottages for the 
reception of the contagious maladies, namely, one for cases of 
scarlet fever, another for cases of measles, a third for those 
of diphtheria, and, perhaps, a fourth for those of whooping- 
cough. No intercourse should be allowed between these cot- 
tages, when they are occupied, for the eruptive fevers espe- 
cially are often communicated by the clothing and persons of 
nurses, and if a child have one of these maladies, he is ren- 
dered no less liable to contract another. In these cottages 
all the precautions should obviously be taken as regards isola- 
tion and disinfection, which are recommended and enjoined 
by boards of health in the care of cases in the cities. 

The Gymnasium and Bath. These buildings are readily 
located, and should be provided with every convenience and 
appliance. 

PART III. 
THE SANITARIUM. 

Hygienic Rules for the Management of Children in the Sani- 
tarium as well as at their Somes. — Facts with which the 
Visitors among the Poor should be familiar. 

Since, as we have seen, one of the chief causes of the in- 
creased death-rate of children in the cities during the summer 
months is dietetic, it is obvious that the subject of feeding de- 
mands careful consideration in every plan or project designed 
to reduce this mortality; and since in' the future manage- 
ment of the sanitarium, and in the wider operations of the 
Thomas Wilson Association, it seems probable that children of 
all ages, will, to a certain extent, be cared for, I have thought 
best to devote a chapter to the consideration of the diet not 



282 MORTALITY OF YOUNG CHILDREN IN CITIES. 

only of infants, among whom the mortality from improper feed- 
ing is greatest, but also to that of older children. I shall en- 
deavor then to point out the kinds of food and the mode of feed- 
ing, which are required for the wants of the system, and are 
most conducive to the healthy development from birth till the 
close of childhood ; and though I may state facts which do not 
seem immediately useful or pertinent to the object for which 
this essay is prepared, I am persuaded that every scientific 
fact relating to this important subject will in the end have a 
practical bearing. 

DIET. 

Obviously, the best food for the infant until it has attained 
a certain age, is that which is provided naturally, and in conse- 
quence of the danger which attends artificial feeding, moth- 
ers should always be encouraged to suckle their infants unless 
they are physically unfit for the task. If they are thus inca- 
pacitated and reside within the city limits, healthy wet-nurses 
should if possible be employed rather than incur the risks of ar- 
tificial feeding, even if the increased expense require retrench- 
ment and rigid economy in other particulars. The infant of the 
city artificially fed during the months in which he should be 
nourished at the breast, is not only the first to suffer from the 
summer complaint when the hot weather arrives, but is more 
apt to acquire a faulty constitution, a rachitic or scrofulous 
diathesis, with its many unpleasant manifestations, than is 
one who has the natural aliment until the time when weaning 
is proper. 

But there are certain states of ill-health in the mother 
which contra-indicate suckling, states in which it should not 
be allowed, both for her sake and the infant's. Among these 
may be mentioned tuberculosis, incipient or confirmed, a de- 
cidedl} r scrofulous state, any chronic disease which reduces 
the strength in a marked degree and renders the milk thin, 
innutritious, and insufficient, and acute constitutional conta- 
gious diseases, which take away the appetite and exhaust the 
strength, as typhoid fever, and severe erysipelas. In other 
acute diseases, not so severe as to endanger life, destroy the 



MORTALITY OF YOUNG CHILDREN IN CITIES. 283 

appetite, or cause much suffering, lactation should be supple- 
mented, if need be, during the continuance of the disease by 
artificial feeding. In acute maladies of the mother of a grave 
type, attended by pain, loss of appetite, and prostration, but 
which will probably soon terminate favorably, it is commonly 
best to allow the infant to suckle two or three times in 
twenty-four hours, sufficiently often to prevent the breasts 
from drying, until convalescence is established. But whether 
or not under such circumstances of ill health, lactation should 
be continued, or to what extent, depends upon the particulars 
of each case, and must be determined by the attending phy- 
sician, who should be fully aware of the importance of pre- 
serving the milk. 

The return of the catamenia, which in some women is as 
early as the third or fourth month after parturition, but is 
not in the average till the sixth or eight month, affects the 
composition of the milk, diminishing its nutritive properties. 
Charles Marchand found in three chemical analyses of the 
milk during menstruation, a diminution of two to four parts 
in the butter, of two to five parts in the sugar, and a diminu- 
tion in the casein and albumen of two to five parts. This 
seems but a trifling change when we recollect that human 
milk in the state of health contains, according to the analysis 
of M. Robin and others, 25 to 37 parts of butter, 37 to 49 
parts of sugar, and 29 to 39 parts of casein, in 1,000 of milk : 
still the alterations in the milk during the catamenial flow, 
some of which have not perhaps been detected, produce in ex- 
ceptional instances more or less indigestion in the nursling 
and even diarrhoea. But these ill effects are transient, sub- 
siding when the flow ceases. The return of the catamenia 
does not therefore contra-indicate lactation in ordinary cases. 

Suckling should in general be discontinued if the mother 
have good reason to believe that she is pregnant. Regard for 
her own health and the development of the foetus require 
this, but if the family remain in the city it is safer for the 
infant to continue nursing during the first two or three 
months of her gestation, if the weather be hot, and no indi- 



284 MORTALITY OF YOUNG CHILDREN IN CITIES. 

gestion or diarrhoea occur, than to be taken from the breast 
and placed on artificial food, for weaning in the city in mid- 
summer nearly always causes the much dreaded summer 
diarrhoea. The proper way under such circumstances is the 
employment of a wet-nurse, or removal to the country and 
weaning there. In the salubrious locality of the ordinary 
farm-house, or in a sanitarium, gradual weaning will probably 
be safe, even in the season of greatest atmospheric heat. 

Sometimes there are insuperable obstacles to lactation in 
the state of the mother's breasts or nipples. The breast may 
be small, so as to secrete very little milk, or there may have 
been a previous inflammation so near the nipple as to occlude 
the milk ducts, or there may be an acute inflammation with 
induration and suppuration of the breast, or the nipple may 
be small and depressed, so that it cannot be seized by the in- 
fant's lips. This last obstacle may sometimes be remedied 
by the use of the artificial nipple, but if the milk be drawn 
with difficulty, such appliance does not fulfil the indication. 
The frequency of cracks and sores upon the nipples which se- 
riously interfere with nursing is known to all practitioners. 

In these various ways lactation is interfered with or pre- 
vented, and the family may not be in such circumstances that 
a wet-nurse can be employed. But the rule is imperative, 
admitting no exceptions, that the infant remaining in the 
city should be wet-nursed through the first year, for the fact 
needs to be repeated and emphasized, that the infant under 
the age of one year, if taken from the breast, though it may 
do well in the cool months, will in all probability be seriously 
sick during the hot season, with indigestion, followed by diar- 
rhoea. In New York we are compelled every summer to wit- 
ness the melancholy spectacle of infants pining away and 
dying upon the bottle, when we are convinced that this great 
waste of life might be prevented or greatly reduced by early 
removal beyond the city limits, to a sanitarium or farm house, 
where pure air and fresh milk can be obtained. 

A large proportion of the mothers of America need de- 
tailed instruction in regard to the suckling and feeding of 



MORTALITY OF YOUNG CHILDREN IN CITIES. 285 

their children, and I will therefore state somewhat fully, at 
the risk of writing upon matters which may not seem exactly 
pertinent to the wants of the Wilson Association, facts which 
every mother and wet-nurse should know, and a knowledge of 
which will tend to diminish infantile sickness and insure a 
more robust development of body. The subject of the diet 
from birth to the end of childhood is so important that it can- 
not, I think, be treated of too exhaustively. 

After the birth of the infant the mother needs to rest a few 
hours, — four or five, or a little longer in tedious and exhaus- 
tive cases, — and then it should be applied to the breast. 
There is frequently a little milk at this time, and the act of 
nursing promotes the secretion and increases the quantit}'. 
The full secretion is not, however, established before the 
third day, and though the infant should be applied to the 
breast about every second hour by day and fourth hour by 
night on the first and second days, it obtains but little nutri- 
ment. Babies are so constituted that they need little food 
until it is naturally provided for them, and the common prac- 
tice of feeding them to repletion with various sweetened mix- 
tures almost as soon as life begins, because they obtain so 
little breast milk, is to be regretted. Filling their stomachs 
in this way has a tendency to prevent their drawing upon the 
nipples with the avidity which is required to stimulate a free 
flow of milk. Besides, as I have many times observed, indi- 
gestion, diarrhoea, and sprue, are common results of this 
injudicious feeding. If therefore the infant be applied to the 
breast every second hour when the mother is awake till the 
third day and be fed nothing besides, there need be no 
anxiety as regards its nutrition. If on the third day the 
breasts do not begin to fill and the secretion be delayed, a 
little fresh cow's milk, diluted with double its quantity of 
warm water, and slightly sweetened, should be given every 
fourth hour, but should be withheld as soon as the flow of 
milk occurs. 

Infants under the age of one month should nurse about 
every hour and a half by day and at longer intervals by 



286 MORTALITY OF YOUNG CHILDREN IN CITIES. 

night, or about ten times in twenty-four hours, for the stom- 
ach of the new born holds but little, and therefore receives 
but little at each nursing, and its digestion is active. The 
interval should be longer at night than in the day-time, so as 
to allow the mother more sleep. In the second month the 
interval should be about two hours, and it should be gradu- 
ally lengthened as the age increases, so that after the fourth 
month nursing should be about every third hour, and after 
the sixth month, when the use of some artificial food is 
proper, every fourth hour. 

The infant should be habituated to nursing at regular in- 
tervals, and when it is, it will ordinarily awaken at about the 
proper time. The practice on the part of the mother of ap- 
plying the babe to the breast whenever it frets, and as a means 
of quieting it, although it have but just nursed, is pernicious 
and should be forbidden. Giving the stomach no time to 
rest, or filling it to repletion, tends to produce indigestion and 
diarrhoea, and to increase the fretfulness. The cause of the 
fretfulness should be sought for that the proper measures may 
be applied. In ignorance of the cause, it is better to quiet the 
restlessness by carrying the child, or even by rocking it, than 
to increase the task of the digestive function. Fretfulness of 
infants is often due to colic or griping in the bowels from gas 
or food that has not fully digested, and the addition of more 
food has a tendency to increase rather than to diminish it. 

If the mother have sufficient breast milk, no other food 
need be given before the fifth month, but many for various 
reasons find it necessary to supplement the nursing before 
that time. If other food be required, a little cow's milk, 
diluted for young infants with water in the proportion stated 
hereafter, may be given two or three times daily. After 
the fifth month cow's milk should be given without dilution. 
If for any reason the cow's milk disagree, one of the farina- 
ceous preparations described hereafter may be added to it or 
substituted for it. 

A fixed rule in regard to the proper time for weaning 
is impossible, for robust mothers with abundance of milk 



MORTALITY OF YOUNG CHILDREN IN CITIES. 287 

should suckle longer than those who are less favorably cir- 
cumstanced. But in the ordinary condition of health, lacta- 
tion should continue till about the age of twelve months, 
when the first molars have pierced or are about piercing the 
gums. The fact heretofore alluded to should be emphasized 
in this connection, namely, that weaning should never occur 
during or just before hot weather, within the limits of the 
city, where the atmospheric conditions are such that there is 
a strong liability to intestinal catarrh in infants, so that slight 
dietetic changes, as the substitution of a food which is not so 
easily digested as the breast milk, may produce it. In New 
York the second summer is greatly dreaded by mothers, on 
account of the known liability of their infants to diarrhceal 
ailments, but the greater risk in the second summer over that 
in the first, which is known in all the tenement houses, is due 
solely to the fact that so many infants have been recently 
weaned, and placed upon new diet when the second summer 
begins. I have frequently advised mothers to suckle their in- 
fants of twelve, fifteen, or eighteen months through the period 
of atmospheric heat, rather than incur the risks of weaning at 
such an unfavorable time, and without apparent detriment to 
either party concerned, when I was convinced that weaning, 
even with judicious selection of artificial food, would result 
disastrously. In a salubrious rural locality, the change from 
the natural to artificial food involves little danger even in the 
hottest weather. 

Unfortunately, there are not a few mothers who, from 
causes enumerated above, are unable to suckle their infants, 
and find it necessary to make use of artificial feeding. Many 
such cases will doubtless come under the care of the Wilson 
Association, either in the sanitarium or elsewhere, since 
infants thus fed from birth, as we have already shown, are 
very liable to disease, either of the digestive organs or of a 
general character, as rachitis or struma. It is important 
therefore to have some rules for guidance as regards the diet 
of such infants. 

There is no food which so closely resembles human milk, 



288 MORTALITY OF YOUNG CHILDREN IN CITIES. 

and which under ordinary circumstances is so good a substi- 
titute for it, as the milk of animals, particularly, since it is so 
readily obtained, that of the cow or goat. Infants under the 
age of six months should take it through the nursing bottle 
at the temperature of about 98i°, and the bottle as soon as 
used should, with the India rubber tip and attachment, be 
put in a quart or two-quart bowl of cold water, to which a 
teaspoonful of bicarbonate of sodium has been added ; and 
this water should be drawn through the tube and nipple by 
suction with the mouth. As the infant under the age of one 
month, when in the normal state, nurses the breast about ten 
times in twenty-four hours, it should have the bottle about 
every two and a half hours. The stomach during the first six 
weeks of life is very small, as we have stated above, resem- 
bling more a dilatation of the intestines than a separate 
organ, not receiving more than one or two ounces of liquid 
without distention. Therefore, while it is fed so often, it is 
evident that the quantity given each time should be small and 
such as will be quickly digested and absorbed. In the first 
month after birth the cow's milk should be diluted with half 
its quantity, or sometimes an equal quantity, of water, from 
the second to the fifth month with one third to one fourth its 
quantity, and after the sixth month it should be employed 
without dilution. 

The shops contain many substitutes for human milk, but 
cow's milk, if it can be obtained fresh from healthy grass-fed 
or hay-fed cows, is to be preferred to any of them for ordinary 
feeding. Condensed milk possesses no advantages which ren- 
der it superior to ordinary milk if the latter can be obtained 
directly from the animal and sufficiently often. 

When shall other food be allowed in addition to cow's 
milk, and what kind of food? Cow's milk, given unmixed 
with other kind of food, does not always agree with the 
infant. Possessing nearly the same chemical constitution as 
human milk, it nevertheless behaves differently, in some re- 
spects, in its digestion. The casein of human milk coagulates 
in light flocculi in the stomach of the infant so as to be read- 



MORTALITY OF YOUNG CHILDREN IN CITIES. 289 

ily acted on by the digestive fluids, while that in cow's milk 
is apt to form large and firm coagula, which are with difficulty 
digested, and which therefore may cause colic and fever and 
make the infant restless, or cause vomiting, by which the 
mass is expelled ; or it may pass the bowels only partially 
digested, and appear in the stools as whitish masses. More- 
over, much of the cow's milk in market gives a more or less 
acid reaction, as we shall see hereafter. Now the casein of 
milk, which is already acid when administered to the infant, 
coagulates more rapidly and in larger masses than the casein 
of breast milk, which is alkaline. But if we mix with the 
cow's milk some bland and easily digested food, which by me- 
chanically separating the caseous particles, prevents the forma- 
tion of large masses, and which, while it has nutritive proper- 
ties, dilutes the milk and enables the digestive fluids to act 
more readily upon it, the desired effect is attained of facilitat- 
ing digestion without impairing the nutritive properties of the 
milk. Experience shows that this object can be effected, and 
that cow's milk, which disagreed with the feeble digestive 
function of the infant, can be made to agree by the admixture 
of certain dietetic preparations. 

The belief has prevailed in the profession that infants, prior 
to the third or fourth month, can digest only a very small 
amount of starch, since the pancreatic and salivary glands, 
whose secretions convert starch into glucose, a necessary 
change in digestion, are almost rudimentary in the first 
months of infancy. Therefore it was held that farinaceous 
or starchy food is unsuitable for young infants, and the re- 
nowned Baron Liebig, wishing to subserve the cause of in- 
fantile hygiene, prepared a food in which, by the action of 
malt, the starch of wheat flour is converted into glucose. 
Liebig's food is extensively used, and mixed with milk or 
given separately it commonly agrees with the youngest in- 
fant, but when given unmixed and in considerable quantity, 
it has in my practice proved too laxative, especially in hot 
weather, from the amount of glucose or grape sugar which it 
contains. I consider it on account of this quality one of the 

19 



290 MORTALITY OF YOUNG CHILDREN IN CITIES. 

best foods for constipated infants, and for all infants except in 
the hottest weather when there is a marked tendency to diar- 
rhoea. But now it is ascertained that the salivary and pan- 
creatic secretions are not the only agents by which the sac- 
charifaction of starch is effected in digestion. The mucous 
surfaces furnish an " epithelial ferment," which aids in the 
change, so that the secretions from the buccal and intestinal 
surfaces assist materially in the digestion of starchy food. 1 

Therefore the theory seems now established that young in- 
fants can digest starch, though not to the extent of those who 
are older. The following are preparations containing starch 
which may be given, mixed with milk, to infants during the 
period of summer heat : Select the best wheat flour, bake 
it in an oven at a slow heat till it has a light fawn color, 
stirring it occasionally. This is very similar to the Ridge's 
Food of the shops. Another way of preparing flour is to press 
and tie it snugly in a bag, which should be boiled four or five 
hours in water sufficient to cover it. It is then like a piece of 
chalk, except the outside, which is moist and must be removed. 
Grate the flour from the mass as it is wanted for use. Flour 
prepared in this way, boiled with water in a gruel and mixed 
with more or less milk according to the age, agrees with most 
infants. It is somewhat constipating, and is therefore espe- 
cially useful in the summer diarrhoea. If it be too constipa- 
ting, it can be mixed with one third its quantity of oatmeal 
or Liebig's Food. Barley-flour is also a useful dietetic article, 
agreeing with most infants. 

But there are not a few cases of infantile diarrhoea in which 
milk given at each feeding, however judiciously mixed with 
farinaceous or glucose preparations, does not agree. Many 
such will no doubt be received from time to time in the sani- 
tarium ; cases, in which diarrhoea with symptoms of indigestion 
occurs, and though temporarily checked by treatment, re- 
turns. Under such circumstances it is better to give the 
milk at longer intervals, at each second or third feeding, or it 

i See resume' on Recent Discoveries in Digestion, by Charles Richert, Review 
Medicale, 1879 ; also remarks by Professor Flint, Jr. 



MORTALITY OF YOUNG CHILDREN IN CITIES. 291 

maybe omitted entirety for a few days and the gruel be given 
alone, or mixed with the white of the egg, or with the ex- 
pressed juice of meat. A gruel made of flour and water is 
not sufficiently nutritive for prolonged use, and if the milk 
disagree and cause colic or diarrhoea so that it is necessary to 
withhold it from most of the feeding, take the white or albu- 
minous part of half a fresh egg, beat it in a saucer or cup, 
and add it to the gruel after the latter has become cool. This 
is usually taken readily by young infants, and it has an excel- 
lent effect in diarrhoeal cases, while it is very nutritious. 
Two or three times through the day, if the infant show signs 
of insufficient nutrition, one or two teaspoonfuls of the ex- 
pressed juice of meat maybe added to the gruel. It is better 
to make only one of these additions to the nursing bottle at a 
time, but I have occasionally employed at the different feed- 
ings in the same day, the egg, milk, and juice of meat with 
advantage. 

Too little attention is given in families generally to the 
kind and quality of milk which their milkmen serve them 
with. In and near a great city much of the milk served to 
the people, all of that which is from cows constantly stabled, 
and from those that are fed on cheap and poor kinds of food, 
is apt to be acid even at the milking, and to disagree with 
the infant, causing diarrhoea. Therefore physicians who have 
had experience with sick children in the cities, emjihasize the 
fact that only milk should be employed of the best quality, 
and from cows that have the range of the fields with 
grass or clover for food, or if stabled in the cool months are 
fed with hay and grain. If milk disagree and be found to be 
decidedly acid when tested by litmus paper, the acidity can 
be removed by adding to it lime-water or a little soda or pot- 
ash, but it is far preferable to substitute for it other milk of 
the best quality that can be obtained, which is less acid. 

Milk should be the chief article of food during the first year, 
and one of the chief during the whole period of infancy, but 
after the age of six months it is proper to allow some solid 
food. The proportion of solid food should be increased and 



292 MORTALITY OF YOUNG CHILDREN IN CITIES. 

that of milk diminished as the infant grows older, but during 
the second and third years as well as during the first, milk 
should be allowed each day at, at least, certain of the meals. 
At the age of twelve months, the artificial food already men- 
tioned may be made of greater consistence, so as to be given 
with the spoon. Crumbs of stale bread broken up should be 
boiled in water sufficient to cover them, for one or two hours, 
then removed, and to the pulp fresh milk be added. This 
may be given one or more times daily in addition to the nurs- 
ing, care being taken that all lumps be reduced to a pulp. 
Beef tea is laxative, on account of the salts which it contains, 
as is also chicken tea, but a small, or moderate amount of it 
may be given once a day. Stale wheat bread or soda cracker 
should be crumbled in it and soaked, so as to be soft. If 
there be diarrhoea, the ordinary beef tea should not be allowed 
to young infants on account of its laxative effect, but the ex- 
pressed juice may be given instead. Few vegetables are 
proper for infants under the age of one year, but the potato 
baked and mashed so as to be like flour, may be given at 
the tenth to twelfth month. It contains a large amount of 
starch, but appears to be readily digested by infants of the 
age mentioned, if given once a day in moderate quantity, with 
a little butter and salt added. In the second year a greater 
variety of food may be allowed, but the full diet of the table 
must not be given till after infancy, or the age of three years. 
In the beginning of the second year the infant is weaned. 
He has twelve teeth, the eight incisors, and four molars, 
which, with their broad surfaces, are designed for chewing. 
Let him have now, each day or second day, in addition to the 
food which has previously been employed, a small piece of roast 
beef, rare done and cut very fine. Other meat, as mutton, 
may sometimes be given instead. After the age of eighteen, 
months, light puddings of farinaceous substances, properly 
prepared, as of rice and corn meal, are proper additions to the 
dietary. 

All the teeth of the first set have appeared at the age of 
two years and five months, and the time has now arrived 



MORTALITY OF YOUNG CHILDREN IN CITIES. 293 

when a more marked transition may be made from liquid to 
solid food. Certain fruits may be allowed, even before this 
period, as also the jellies of most berries, and of fruits, which 
being deprived of seeds and parenchyma are for the most part 
readily digested, while they give a relish to the farinaceous 
food with which they are eaten. Pastries as ordinarily 
made, whatever fruits they may contain, are too rich and in- 
digestible for young children. The following judicious rule 
for the preparation of fruits for children, copied in popular 
treatises on hygiene of infancy and childhood, is from " Mur- 
ray's Modern Cookery Book." .... " Put apples sliced 
or plums, currants, gooseberries, etc., into a stone jar, and 
sprinkle among them as much Lisbon sugar as necessary ; 
set the jar in an oven or on a hearth, with a teacupful of 
water to prevent the fruit from burning ; or put the jar into 
a sauce-pan of water till its contents be perfectly done." 
Berries and fruits thus prepared, and the fruit jellies, are 
best eaten spread on bread and butter, or on soda crackers. 

It is obvious, from what has been stated above, that no 
rules or measures for the preservation of infantile life in the 
cities, during the summer, can be effectual in the highest de- 
gree, that do not particularize in regard to the quantity, as 
well as quality of the food, and the mode of feeding ; and as 
in the future operations of the sanitarium it is probable that 
children of all ages will be cared for and fed, I shall detail, 
presently, observations, which show what quantity of food is 
required, both in infancy and childhood, to furnish the nutri- 
ment which is necessary for normal growth. There is la- 
mentable ignorance in community as regards the dietetic needs 
of young children. The belief that children on account of 
being so much smaller require much less nutriment than 
adults, leads many astray. The following statistics, while 
showing how much food children require to do well and how 
much they receive in the large and well conducted institu- 
tions of New York City, will surprise many. The fact is, the 
digestion of children is more active than that of adults, and 
they suffer more from hunger if their meals are delayed be- 



294 MORTALITY OF YOUNG CHILDREN LN CITIES. 

yond the usual time. The tissues undergo more active molec- 
ular change than those of adults, so that they need more nu- 
triment for the waste, and they require additional nutriment 
for the purposes of growth. 

The children upon whom the following observations were 
made are grouped according to their ages. New-born infants 
differ in some respects physiologically from those that are 
older, and they constitute the first group. The term " new- 
born " being applied to those under the age of five weeks. 
The second group embraces infants between the ages of two 
and ten months. These furnish a fair average of the dietetic 
requirement during the period of infancy after the second 
month. The observations embraced in the remaining tables 
relate to children who have passed beyond the age of lactation 
and been weaned. 

It will be seen from the statistics that new-born infants re- 
quire less milk than those who are older, and that after the 
first month the amount required is pretty uniform during the 
period of lactation. 

For the purpose of procuring accuracy in the following ob- 
servations, I obtained Fairbanks' Scales, weighing to the half 
drachm. The infants were accurately weighed before, and 
after each nursing, and the artificial food was weighed before 
and after each feeding. In this way the quantity taken at 
each meal was determined. The weights used were avoir- 
dupois. The observations were made, at my request, by Dr. 
Kate Parker, resident physician of the New York Infant Asy- 
lum, and by Dr. Chadbourne, resident physician of the New 
York Foundling Asylum, and I can vouch for their accuracy. 
The avoirdupois ounce contains 437.5 grains, and Dr. Chad- 
bourne ascertained, by very careful weight and measurement, 
employing the metric system for its greater accuracy, that 
one fluid ounce of human milk, with a specific gravity of 
1,031, weighed 451.9 grains. With these data it was easy to 
determine the quantity in bulk of the milk from its weight. 
The observations in each case extended through twenty-four 
hours. 



MORTALITY OF YOUNG CHILDREN IN CITIES. 



295 



TABLE I. — Age under Five Weeks. 





Name. 


Age. 


to 

3 

S3 

o sj 


Milk Nursed 


in 24 Hours. 


No. 














Quantitv in 


Quantity in 








fc 


Weight. 


Fluid Ounces. 










Oz Dr. 




1 


Josephine Folev . . . 


17 d. 


11 


10 l 


9.75 


2 


Henrv Cunningham 


16 d. 


9 


13 5 


13.24 


3 


Henrv Jackson . . . 


19 d. 


9 


10 3 


10.07 


4 
5 


"RiL-p 


5 d. 

6 d. 


12 
12 


22 7 
15 54- 


22.22 
15.25 


Henrv Benton . . . 


6 


Wm. Fletcher .... 


5d. 


12 


10 1£ 


9.88 


7 


Nora Has tie . . . . 


14 d. 


12 


17 3 


16.85 


8 


Carl Flask 


5 d. 


12 


5 4 


5.37 


9 


Clarence Humphrey- 


1 m. 5 d. 


8 


11 H 


10.84 


10 


Frederick Dighle . . 


7d. 


12 


14 4 


14.08 


11 


Edward Stace . . . 


6 d. 


12 


8 1 


7.74 


12 


Rosa Brown .... 


3 w. 


12 


14 1 


13.68 



From these statistics, it is seen that each of these infants, 
who were all under the age of five weeks, and all but one un- 
der that of twenty days, nursed in the average 12.41 fluid 
ounces of breast milk in twenty-four hours, and as the average 
number of nursings for each during the day was 11.0, the 
quantity of milk received at each nursing averaged only a lit- 
tle more than one fluid ounce, 1.12, or to state the result of 
these observations in a different way, in 133 nursings of 12 in- 
fants in the twelve hours of day and twelve of night, the total 
quantity of milk received was 148.97 fluid ounces, with a 
daily average of 12.41 ounces for each infant, and 1.12 fluid 
ounce for each nursing. These infants were selected on ac- 
count of their healthy condition, none of them showing 
symptoms of imperfect nutrition. They were selected as fair 
examples of healthy infants under the age of five weeks. 
The practical benefit from these observations is apparent. We 
can do no better than imitate what is natural in the feeding 
of infants, and if, for any cause, lactation of a new-born infant 
be prevented, it should not be fed more than one and one 
fourth ounces, each two and a half hours, of cow's iriilk, pre- 



296 MORTALITY OF YOUNG CHILDREN IN CITIES. 



pared as directed above, so as to resemble as closely as possi- 
ble, human milk. New-born infants, deprived of the natural 
mode of feeding, are apt to be over-fed by anxious mothers, 
with the inevitable result of indigestion, diarrhoea, and un- 
healthy stools, colic and sprue. Statistics like the above may 
assist in correcting such error. 

TABLE II. — Ages from Five Weeks to Ten Months. 









m 
u 


Milk Nursed 


in 24 Hours. 




Name 


Age. 








No. 












• 2P 


Quantity in 


Quantity in 








£'" 


Weight. 


Fluid Ounces. 










Oz. Dr. 




1 


Agnes Sunkle . . . 


6 m. 


8 


26 H 


25.3 


2 


Jessie Bradley 






4 m. 


9 


38 i 


36.8 


3 


Walter Gorman . 






3£m. 


8 


24 2 


23.5 


4 


Lottie Brooks . . 






7 m. 


10 


27 3^ 


26.6 


5 


Willie Leonard . 






5} m. 


11 


28 7 


28.0 


6 


John Clay . . . 






5 m. 


10 


29 7 


29.0 


/ 


Agnes West . . 






3^m. 


8 


19 2 


18.6 


8 


Freddy Van Buren 






2 m. 10 d. 


7 


24 4 


23 . 7 


9 


Eddie Wilson . . 






6 m. 


10 


12 4i 


12.2 


10 


Frank Smith . . 






3i m. 


8 


26 7 


26.1 


11 


Sarah White . . 






4 m. 


8 


23 5 


22.9 


12 


John Gafney . . 






9 ra. 


8 


24 11 


23.4 


13 


Bernhard Joseph 






7 m. 


8 


27 4 


26.6 


14 


Thomas Cole . . 






6 m. 


10 


26 6-t 


26.0 


15 


Astie Russel . . 






6 m. 


10 


21 6 


21.1 



The average quantity of milk, which these infants, who 
were all well-nourished, received in the twenty-four hours, 
was 24.65 fluid ounces. The quantity received at each nurs- 
ing was 2.73 fluid ounces in the average. Comparing the 
statistics in the two tables we find that infants in the first 
month require only half the nutriment which is needed in 
the subsequent months of the first year. In other words, the 
nursling, after the first three or four weeks, requires about one 
ounce of milk, for each hour between the nursings. If there- 
fore it be bottle-fed, every third hour, with cow's milk, or 
other food, so prepared as to have about the same amount of 
nutriment as breast milk, three or three and a half ounces 
would be sufficient for each feeding. 



MORTALITY OF YOUNG CHILDREN IN CITIES. 



297 



The following observations, relating to the diet of children 
who have passed beyond the age of lactation, were made in 
the New York Foundling Asylum, with all possible care in 
order to avoid errors. In this institution children are not 
stinted in their eating, but those who eat little are reminded 
of their remissness, and are urged to eat more, so that no one 
leaves the table hungry. On the days in which Dr. Chad- 
bourne made the observations vegetables, except potatoes, 
were withheld, so that computation of the quantity of food 
consumed would be more accurate. 

TABLE III. — Observations Relating to the Diet during Twenty- 
four Hours, of Twenty-eight Healthy Children, between the Ages of 
Two and Three Years, with an Average Age of Two Years Eight 
Months. 





Total Amount. 


Average for each. 


Bread . 
Butter . 


Breakfast. 


6 lbs. 4 oz. 1 dr. 

13 oz. 5 dr. 
22 lbs. 14 oz. 2 dr. 1 

8 lbs. oz. 5 dr. 

6 lbs. 13 oz. 7 dr. 
17 lbs. 9 oz. 7 dr. 

19 lbs. 12 oz. 1 dr. 

7 lbs. 1 oz. 2 dr. 

14 oz. 7 dr. 


3 . 5 oz. 
.45 oz. 


Milk . " - - - 


12.7 fl. oz. 


Meat . 
Potatoes 


Dinner. 


4.6 oz. 
3.9 oz. 


Milk . 




9.4 fl. oz. 


Milk . 


Supper. 


10.5 fl. oz. 




4.0 oz. 


Butter 


. 53 oz. 



1 354.6 fluid ounces. 
AVERAGE FOR EACH CHILD PER DAY. 

Bread 7.5 oz. 

Butter 98 oz. 

Meat (beef) 4.6 oz. 

Potatoes 3.9 oz. 

Milk 32.6 fl. oz 



298 



MORTALITY OF YOUNG CHILDREN IN CITIES. 



TABLE IV. — Observations upon Twelve Children between the Ages 
of Three and Six Tears: Average Age, Four Tears Ten Months. 





Total Amount. 


Average for each. 


Bread . 
Butter . 


Breakfast. 


4 lbs. 6 oz. 3| dr. 
5 oz. 2 dr. 
280 fl. oz. 

9 lbs. 1 oz. 3 dr. 

1 lb. oz. 1 dr. 
9 lbs. 12 oz. 7 dr. 
112 fl. oz. 

2 oz. 2£ dr. 

2 lbs. 4 oz. H dr. 

5 oz. 5| dr. 
192 fl. oz. 


5 . 86 OZ. 
.427 oz. 


Milk 


23.3 fl. oz. 


Beef . 


Dinner. 


12.1 oz. 


Bread 


1 . 6 oz. 


Eice 


13.0 oz. 


Milk 


9 . 3 fl. oz. 


Butter 




Bread . 
Butter . 
Milk . 


Supper. 


3 . oz. 
16.0 fl. oz. 









AVERAGE PER DAT FOR EACH CHILD. 



Milk . 
Beef 
Bice . 
Bread 
Butter 



48.6 fl. oz. 

12.1 oz. (avoird. 

13.0 oz. " 

10.3 oz. 

1.08 oz. " 



MORTALITY OF YOUNG CHILDREN IN CITIES. 



299 



TABLE V. — Observations relating to the Diet of Twenty-four Chil- 
dren, Twelve Boys and Twelve Girls, between the Ages of Four Tears 
and Ten Years : Average, Six Years Ten Months. 





Total Amount. 


Average for each . 


Breakfast. 

Bread 

Butter 

Milk 


7 lbs. 13 oz. 3 dr. 
12 oz. 3^- dr. 
348 fl. oz. 

18 lbs. 11 oz. dr. 
15 lbs. 8 oz. 3 dr. 

1 lb. 6 oz. \ dr. 

192 fl. oz. 

4|dr. 

6 lbs. 2 oz. 3£ dr. 
384 fl. oz. 

11 oz. 5| dr. 


5.21 oz. 
.51 oz. 
14.5 fl. oz. 


Roast Beef 
Potatoes . 
Bread . . 
Milk . . 


Dinner. 


12.46 oz. 
10.30 oz. 
. 92 oz. 
8.0 fl. oz. 


Butter 


.012 oz. 


Bread . . 


Supper. 




Milk 


16.0 fl. oz. 


Butter 


.16 oz. 









AVERAGE PER DAT FOR EACH CHILD. 

Roast beef 12.46 oz. 

Bread 10.23 oz. 

Potatoes 10.3 oz. 

Butter .99 oz. 

Milk 38.5 fl. oz. 

Compare the above observations with those of Professor 
Dalton, who estimates that a healthy adult taking active ex- 
ercise requires each day, — 

Meat 16 oz. 

Bread 19 oz. 

Butter 3^- oz. 

Water 52 oz. 

while one leading a sedentary life needs considerably less. 

It will be seen by the above tables, that even more food 
appears to be needed during the period of childhood, than in 
adult life. We would suppose this to be so without statistical 
evidence, for the active exercise, and rapid and progressive 
growth of this period, would necessarily require a large 



300 MORTALITY OF YOUNG CHILDREN IN CITIES. 

amount of nutriment. Moreover while adults do well with 
solid food and water, statistics show, that the best diet for 
children, who have passed beyond infancy, is one of milk 
with solid food, for at least breakfast and supper. 

Although we are able, by observations, to determine the 
average amount of food required in twenty-four hours, by 
children of various ages, it would be wrong to limit the diet 
to a fixed quantity, for some need more than others. A child 
should never go hungry after a meal. In some of the best 
conducted institutions of New York, the children eat of plain 
food all that they desire at each meal, while in other institu- 
tions, the food at supper is limited, but is abundant at the 
other meals. As children go to bed so soon after supper, it 
is proper to have this meal light, and of such food as is easily 
digested. 

I have obtained the following dietaries of three of the larg- 
est and best conducted of the New York Institutions, the 
children in which exhibit a healthy and contented appear- 
ance, and have little sickness. 

New York Orphan Asylum. 

This institution, of which Mrs. Alexander Hamilton, after the death of her 
distinguished husband, was during many years first directress, is located in West 
Sevent) fourth Street, and the children in it, about one hundred and eighty, eat 
all which they wish at each meal. 

BREAKFAST. 

Two or three thick slices of bread with milk ; no butter. 

DINNER. 

This always consists of hearty food, as corn beef, fresh meat, pork and beans, 
fish, potatoes, with other vegetables ; bread ; no soups. 

SUPPER. 

Bread and milk. 

New York Foundling Asylum. 

Inmates, about six hundred, all under the age of eight years. Those over the 
age of two and a half years have the following diet : — 

BREAKFAST. 

Bread and milk ; butter ; eggs for the delicate ; occasionally oat-meal porridge. 



MORTALITY OF YOUNG CHILDREN IN CITIES. 301 



Eoast beef, potatoes, and four times each week other vegetables, as peas, beans, 
tomatoes, turnips, cabbage, and parsnips. Bread and milk for delicate children. 
On Monday rice, and on Friday eggs. 

SUPPER. 

Bread and milk ; butter; berries in their season ; apple-sauce; cake; syrup. 

The roast beef is sliced, passed through a machine chopper, so as to be made 
into hash, which is then moistened by the gravy, or juice of the meat. In the 
form of hash it is easily digested, while it contains all the nutritive properties of 
the beef. It would be well if this mode of preparing beef were imitated in other 
institutions and in families. 

Protestant Episcopal Orphan Asylum. 

BREAKFAST. 

One pint of milk; five to seven large slices of bread (two thirds of a pound to 
one pound.) 

DINNER. 

Monday. — Indian meal and syrup, or rice and sugar ; bread ; at times pota- 
toes and codfish. 

Tuesday. — Strong beef soup, containing onions, carrots, potatoes, turnips, 
parsley, celery, and rice ; bread. 

Wednesday. — Codfish and potatoes ; bread. 

Thursday. — Same as on Tuesday. 

Friday. — Corned beef, corned pork ; bean soup. 

Saturday. — Bice or Indian meal ; hominy; potato stew. 

Sunday. — Cold corned beef; boiled potatoes; bread. 

SUPPER. 

Same as breakfast. 

All the ordinary berries and fruits are also liberally used in their season. 

BATHHTG. 

Bathing is now recognized in all civilized countries as one 
of the chief promoters of bodily comfort and health. The 
first bathing of the infant, which is immediately after birth, 
should be in water at a temperature a little below that of the 
blood, namely, at about 96°, after which the general bath is 
inadmissible until the navel string is detached. In the infant 
reaction of the surface when chilled is tardy and uncertain, 
and therefore there is great danger of catching cold when the 
surface is cooled by water, and does not quickly react. It is 
a matter of daily observation that infants become chilly and 



302 MORTALITY OF YOUNG CHILDREN IN CITIES. 

their extremities remain cool in a medium, whether air or 
water, in which older children and adults would have com- 
fortable warmth. Therefore they are liable to contract bron- 
chitis, sore throat, intestinal catarrh, or other inflammation 
from very slight exposures. This fact must be borne in 
mind in considering the subject of bathing. 

During the first year after the detachment of the navel 
string, the bath should be employed daily, but not longer 
than three minutes, during which time thorough ablution can 
be performed. Different authorities disagree in regard to 
the proper temperature of the bath during the first months 
of infancy. Steiner of Prague, a high authority in children's 
diseases, says," During the first nine months the infant should 
have a daily bath a little above blood heat," .... but most 
state a temperature a little below blood heat. In my opinion 
it should be 92°, which is considerably below blood heat, but 
which communicates a moderately warm sensation to the 
hand. After the age of ten months or even of eight months 
for vigorous children, the temperature of the bath may be re- 
duced to 90°, and it should not be lower than this during the 
remainder of infancy, or if it be used a little lower, care should 
be taken to produce reaction by brisk rubbing and exercise 
after a short bath. At the close of infancy, namely, at two 
and a half years, the temperature may be still farther reduced, 
but it should not even for the most robust children of eight or 
ten years be below 78°, which is recorded on our thermome- 
ters as the temperature of summer heat, and is about that of 
our northern lakes during midsummer. 

The rules given in the books not to bathe or direct a child 
to be bathed immediately after eating, or after much exercise, 
when the pores of the skin are perspiring, should be heeded. 
The head should first be wet with the water, and castile soap 
should be applied over the surface to insure cleanliness. The 
strongly scented toilet soaps sometimes contain rancid fats, 
or other deleterious substances, and should be regarded with 
suspicion. In hot weather a daily bath is advisable, but in the 
cooler months it is sufficient if the child bathe twice or three 



MORTALITY OF YOUNG CHILDREN IN CITIES. 303 

times in the week. If from lack of conveniences, or for other 
reason, general bathing be dispensed with and the surface be 
washed from a basin or bowl, cooler water may be used 
than would be proper for the general bath, and a longer time 
to complete bathing would evidently be required. The bath- 
room should be comfortably warm, and after the bath the 
surface should be briskly rubbed with flannel, or in case of 
the older children with a suitable coarse towel, and exercise 
afterward encouraged to insure full reaction. In NeV York, 
in one of the largest and best managed asylums, both boys 
and girls are allowed to bathe in bath houses in the Hudson, 
when the water and weather are not too cool. 

It may be well to add to these general remarks on bathing 
the recent remarkable statement of a high authority on ther- 
mometric observations and temperature, that during hot days 
a bath in hot water employed in the hours of greatest at- 
mospheric heat, tends to reduce the heat of body and to pre- 
serve its normal temperature during the remainder of the day. 
Wun derrick says, " in tropical countries and in very hot sea- 
sons, no means of cooling is so lasting as a bath or a douche 
of very warm water. 

CLOTHING. 

One of the most important duties of the mother or nurse, 
is the selection of clothing for children which will be suitable 
for their age and the season. In the matter of dress as in 
that of diet, many errors are unconsciously committed. In a 
room of proper temperature, which during the cool months 
should be 70° for infants and 68° for children old enough to 
run about, the head should never be covered unless in case of 
young infants, the sides of whose heads as well as their necks 
and shoulders may be lightly covered in sleep. It is the 
common practice to leave off the " belly band " which is ap- 
plied after birth, when the infant has reached the age of 
three or four months, but from the fact that infants so often 
take cold, especially at night by throwing off bed clothes, 
both in cool weather, when the temperature of the apartment 



304 MORTALITY OF YOUNG CHILDREN IN CITIES. 

may fall below 70°, and in summer when there are currents 
of air through open windows, I advise the continuance of 
the band during the first year or eighteen months. In the 
summer it should be made of light merino, and in the winter 
of flannel. It should never be so thick and heavy as to be 
uncomfortable, or so snug as to interfere in the least with the 
free movements of the chest and abdomen in respiration. It 
should extend to and not over the ribs, and should be se- 
cured either with safety pins or a few stitches. If excoria- 
tions or prickly heat appear on the skin under the band in 
hot weather, a very common eruption in infancy, the surface 
should be dusted with subnitrate of bismuth or a mixture in 
equal parts of lycopodium and oxide of zinc, and a single layer 
of linen should be applied over it and under the band. If 
the eruption be severe, it might be best to substitute a linen 
or soft muslin band for a time in place of the merino. 

A cardinal principle in the clothing of children is that the 
garments should always be so loose as not to interfere in the 
least with the functional activity of organs. The fitting and 
putting on of the dress is left too much to the discretion 
of the nurse, who is usually ignorant of the important 
facts in physiology, and, unwittingly and with the best inten- 
tions, injures her charge. I have often interposed to loosen 
the dress of young infants, which was so tight as to sensibly 
embarrass respiration, and the case of a new-born infant has 
been reported to me in which it seemed probable that death 
resulted from this cause. Infants especially who are so liable 
to pulmonary collapse and intestinal hernia, should have loose 
covering of both chest and abdomen. Pressure over the stom- 
ach always feels uncomfortable, and this organ, almost as 
much as the lungs, needs full expansion and free movement, 
in order to perform its function of digestion properly. The 
same is true also of the intestines, but they tolerate compres- 
sion better, and their movements are less impeded than those 
of the stomach by too tight dressing. Another part, where 
too snug an application of the dress does very great harm, is 
the neck, since moderate pressure in this region may retard 



MORTALITY OF YOUNG CHILDREN IN CITIES. 305 

the circulation of blood through very important vessels, 
namely, those which supply the brain, or return blood from 
this organ. The dress about the neck should always be so 
loose that the four fingers of the nurse can be readily intro- 
duced underneath it. Skirts upon girls are sometimes sup- 
ported by being tied tightly around the waist and over the 
stomach. This should never be allowed, but skirts should 
always be supported by shoulder straps, and be loose around 
the waist. 

Clothing protects the body according to its thickness and the 
feebleness of its power of conducting heat. Woolen, fur, and 
feather garments have very low conducting power, and wool, 
from its plentiful supply and cheapness, must always be the 
material which is chiefly worn in the winter season ; while 
cotton, and in still greater degree, linen, are active conductors 
of heat, allowing its quick escape from any part of the body 
which it covers, and they are therefore the proper material for 
summer clothing. 

The color of a garment matters little as regards the escape 
of heat from the body, for whatever its color its surface next 
the body is necessarily dark from the exclusion of light ; but 
the color is important as regards the absorption of heat from 
the atmosphere and the solar rays. Black has the highest 
absorptive power, while white has the least, and the mixed 
colors have absorptive powers which are intermediate. In ex- 
periments made with shirtings of different colors, while white 
received 100° F., black received 208° F. A light color is 
therefore the best to dress children in in the hottest weather. 

The covering, which is proper for the head of a child when 
out-door, must evidently vary considerably in different sea- 
sons, and in different states of weather. Many a young child, 
with scanty growth of hair, has contracted that painful dis- 
ease, inflammation of the ear, followed perhaps by a pro- 
tracted discharge, and more or less impairment of hearing, in 
consequence of taking cold from insufficient covering of head 
and ears in inclement and changeable weather. Even leaving 

20 



306 MORTALITY OF YOUNG CHILDREN IN CITIES. 

off accidentally a band or tie, to which a child is accustomed, 
will sometimes give it a cold. 

In this connection, I wish to call attention to the common 
and dangerous practice among the poor of allowing children 
to go bare-headed in the sun, during the season when the at- 
mospheric heat is highest. Not a summer passes in which I 
do not meet cases of inflammation of the brain, which I be- 
lieve to be largely due to exposure to the sun's rays. There 
is no better and safer covering of the head of a child, who is 
allowed to go in the open air during the hot weather, than the 
light, cool, and inexpensive straw hat. 

The feet should always be warm and dry, the shoes worn 
in wet weather being water-proof ; and special care should 
be taken in the selection of shoes, that they be pliable and 
loose, so as to allow freedom of growth without compression 
of any part. If during the period of growth, proper precau- 
tions are taken in this respect, the chiropodist would have 
little to do in subsequent years. Corns, bunions, and ingrow- 
ing toe-nails originate from shoes, hard and unyielding, or 
too tightly fitting. 

SLEEP. 

The new-born infant requires from fifteen to eighteen hours 
sleep each day. If it do not have this amount and be wake- 
ful, it is probably not well. It sleeps therefore most of the 
time when not awake for nursing, bathing, and change of 
clothing. As it grows older, a less and less amount of sleep 
is required. At the age of three years, about nine hours are 
needed, and it is better, in my opinion, for healthy develop- 
ment, to allow children of this age one or two hours of sleep 
in the middle of the day. They indeed often take it by fall- 
ing asleep on the sofa, or floor, or in places where they are 
liable to take cold through currents of air, and scant cover- 
ing. 

Immense harm has been done to children, who were wake- 
ful, by nurses and mothers too, who have given them active 
and dangerous drugs, as laudanum or morphine, under some 



MORTALITY OF YOUNG CHILDREN IN CITIES. 307 

enticing name as soothing syrup or cordial. A wakeful and 
fretting child is not well. Its ailment may be trivial or 
grave, but it should never, under such circumstances, receive 
from mother or nurse any of those proprietary mixtures hav- 
ing seductive names which the shops contain. If it need 
medicine, it should be examined and prescribed for by the phy- 
sician. It is scarcely necessary to call attention to some ac- 
cepted and important facts, regarding the dormitory of chil- 
dren. A free ventilation is required either through ventilators, 
or open windows, and a sufficient number of cubic feet of air 
should be allowed for each sleeper. A small room should not 
contain more than two children. Curtains should not as a 
rule be employed, and no open vessels of foul water should 
stand in the room, or anything else, which may contaminate 
the air. The garments worn through the day must be en- 
tirely removed and hung up away from the bed. 

In the asylums of New York, where from long and abun- 
dant experience the management of children is systematized, 
infants and the younger children are usually put to bed be- 
tween six and seven, and the older children between seven and 
eight o'clock, the last meal or supper, as I have stated else- 
where, being light and easily digested. 

EXERCISE. 

Exercise is an important hygienic requirement. Harm often 
results from modes of exercise which are not adapted to the 
age. Occasionally I meet cases of permanent bow-leg, which 
has manifestly resulted from attempts to make the infants 
stand at the age of four or five months. They should never 
be encouraged to walk or stand till about the age of one 
year, and if they do at the age of nine or ten months let 
it be voluntary, and not taught by standing them upon their 
feet. In case of infants with rachitis, which disease is com- 
mon in the cities, and is characterized by a lack of lime-salts 
in the bones, and can be detected by great backwardness in 
teething, attempts to stand or walk for any length of time 
should be discouraged, till by the use of lime-salts and cod 



308 MORTALITY OF YOUNG CHILDREN IN CITIES. 

liver oil, and improvement of the general health, the rachitis 
is cured. Much of the permanent deformity which mars the 
beauty and symmetry of adult life originates in rachitis and 
might have been prevented. 

The infant before he is old enough to stand takes sufficient 
exercise in a way that is natural and harmless. Let him 
lie upon his back in the crib, or on the floor with a blanket 
under his body and a pillow under his head, and all his clothes 
loose so as not to restrain the free movements of his limbs. A 
healthy infant seems to enjoy this attitude, moving all his 
limbs sufficiently to give them the required exercise, and 
evincing his delight and exuberance of life by utterances 
which are as expressive as words. 

In the cool months of our latitude infants should not be 
taken out-door until the age of three months, and then only 
for a brief time in the warmest part of the day, but in the 
summer they should begin to receive out-door air and exer- 
cise at the age of one month. In warm weather the face 
should never be covered by a veil or otherwise, and air and 
light should have free access to it. The rays of the sun, 
however, from a clear sky should be excluded either by a par- 
asol, or the shade of trees or houses or the carriage in which 
the infant may be carried. In cold weather, or when there is 
a strong wind, the protection of a veil is needed. Rude toss- 
ing of infants, which is common in families, should always be 
forbidden. Its effect on the cerebral circulation is likely to 
be bad, and it involves risk of a serious accident. In one 
instance to my knowledge, death resulted from such acci- 
dent. 

Walking, as it is the natural, so it is the best, exercise for 
the older infants and during the period of childhood. It pro- 
motes digestion when not carried to the extent of fatigue, and 
gives gentle exercise to all the muscles. The baby-carriage 
answers a useful purpose, when combined with walking. 
With the ordinary hired nurse it is safer for the infant to be 
taken out in this vehicle than in the arms, for if the nurse 
in careless walking should trip, great harm might result. In 



MORTALITY OF YOUNG CHILDREN IN CITIES. 309 

one instance which came under my notice convulsions and 
idiocy were plainly referrible to the fall of an infant from the 
nurse's arms upon its head. 

The ordinary lawn sports of childhood, as croquet for both 
sexes, playing ball or quoits for boys, which are rendered 
more exciting by the spirit of rivalry, are also useful for mus- 
cular exercise and development, while they involve little dan- 
ger. Swinging is a pleasant pastime to most children, and 
with the propulsion required it gives gentle but efficient ex- 
ercise to the muscles. 

Many of the gymnastic exercises are too severe, and involve 
too much risk of ruptured tendons, sprained joints, and even 
of dislocated or broken limbs. 

But with all the ingenious inventions to procure sports and 
pastimes for children, there are none better than gardening 
and farming, where facilities will allow it, conjoined with, the 
ordinary household duties. The healthy and robust develop- 
ment of the farming population, — their almost complete im- 
munity from rachitic and scrofulous ailments, is attributable 
to their out-door mode of life, and the many kinds of health- 
ful work which farm life requires. Such work is always in 
the highest degree beneficial for children old enough to par- 
ticipate in it, while it develops the habit of productive in- 
dustry. 




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